No. 9, Winter 2000

BC’s Mental Health Journal Cross Cultural Mental Health poster (original in full-colour) c/o CMHA, Novia Scotia Mental Health Initiativeposter (original in full-colour) c/o CMHA, Division’s Cross Cultural

Attitudes

Approaches

Accessibility

Acceptance editor’s message

he story underlying Dr. Terry ground? If not, where are the due to migration from countries TTafoya’s editorial [opposite gaps? And what can we learn from outside of Canada, 76% of whom page] is a powerful illustration of the people who deal with mental were people from an Asian the simple truth laid out in its fi- illness — i.e., consumers and fam- country. nal sentence: “There are different ily members — who come from dif- BC’s methods of healing because ferent backgrounds? What can we This edition reflects changes in Mental there are different needs of peo- learn from the traditions of knowl- the CMHA Editorial Staff. Eric Health ple.” And while the lesson applies edge and wisdom that people Macnaughton takes over the du- Journal to what the biomedical model bring with them? ties as Editor from Dena Ellery, might think of as “treatment,” it who has returned to school full- obviously relates to the other is- Considering this issue of cross cul- time. Sarah Hamid continues in Visions sues of cross cultural mental tural mental health is crucial, a Design and Production Editor health that this edition of Visions because there is still a long way capacity. Vinay Mushiana, the Co- is a quarterly publication pro- will address: access to services, to go, and much to learn in rela- ordinator of the Cross Cultural duced by the Canadian Mental appropriate methods of ass- tion to all of these questions. Let Mental Health project, has acted Health Association, BC Division. It is essment, and “healing” in all it be said, too, that discovering an- as Co-Editor of this special issue. based on and reflects the guiding philos- its manifestations (treatment, swers to these questions is not just ophy of the CMHA, the “Framework for Sup- rehabilitation, and community a narrow endeavour, done for the With these changes, we remain port.” This philosophy holds that a mental support). benefit of certain citizens. Expand- committed to ensuring that health consumer (someone who has used ing the wealth and scope of our Visions addresses topical issues mental health services) is at the centre of People have different needs be- approaches to mental illness for people with mental illness and any supportive mental health system. It also cause they come from different brings increased hope to all indi- all those — family members, advocates and values the involvement and backgrounds and have different viduals. As with the legend (see Dr. friends, and professionals — who perspectives of friends, family members, experiences. As the articles in this Tafoya’s article), this process will play a significant role in their service providers, and community. In this issue will explore, they under- transform our understanding of lives. We recognize that some of journal, we hope to create a place where the stand “mental health” in different mental illness into “not something these issues may be controver- many perspectives on mental health issues ways; they view “mental illness” that will disappear, but something sial, and that this edition is per- can be heard. and the stigma so often attached that can be dealt with,” and a trou- haps no different, as it deals with to it, differently. As we will also ble from which people can heal, sensitive issues related to ethnic- The Canadian Mental Health Association explore, being an immigrant, a regardless of who they are and ity, culture, and race. While some invites readers’ comments and concerns refugee, or a visible minority from where they come. disagreements are inevitable, we regarding articles and opinions expressed brings another layer of experi- feel strongly about ensuring that in this journal. Please e-mail us at ence that must be understood if This edition of Visions carries for- the journal remains a forum for [email protected] or send your letter with we are to respond with equal care ward the work of the CMHA BC dialogue between people of dif- your contact information to: to all those who come through Division’s Cross Cultural Mental fering or opposing viewpoints. We the doors of the mental health Health Project, which has promot- hope you enjoy and benefit from Visions Editor system. ed organizational change aimed this edition of Visions on Cross CMHA BC Division at making BC Division reflective Cultural Mental Health and look 1200 - 1111 Melville Street Are the concepts and approach- and inclusive of the ever-changing forward to your responses. Vancouver, BC es we use to foster recovery face of this province. The latest V6E 3V6 meeting the challenge for all our census figures show BC to be the citizens, regardless of their fastest growing province in the Eric Macnaughton Subscriptions are $25 a year for four issues. ethnic, cultural, or racial back- country. Of this growth, 43% was and Vinay Mushiana For more information, call us at 688-3234 or if you are calling from outside the Lower „ Editorial Board Nancy Dickie, Jane Duval, Dr. Raymond Lam, Dr. Rajpal Singh Mainland, dial our toll-free number: Executive Director Bev Gutray 1-800-555-82221-800-555-8222. Editor Eric Macnaughton, Vinay Mushiana (co-editor this issue) Staff Contributors Vinay Mushiana, Eric Macnaughton, Terry Morris, The opinions expressed in this journal are Sarah Hamid, Marie-Claude Lacombe, Catharine Hume those of the writers and do not necessarily Design / Production Editor Sarah Hamid reflect the views of the Canadian Mental Printing Advantage Graphix Health Association, BC Division, or its branch offices. „ The Canadian Mental Health Association is grateful to the BC Ministry of Health which has assisted in underwriting the production of this journal.

2 Guest Editorial ...... 3 Social Issues ...... 24 Glossary of Key Terms ...... 4 Ethnocultural Consumers & Families ...... 29 ooNTENTSNTENTS Perspectives on Mental Health and Illness .... 5 Provincial Updates and Reflections ...... 34 CC Cultural Competence for Providers ...... 14 Resources ...... 39 Programs and Approaches ...... 18

Visions: BC’s Mental Health Journal Cross Cultural Mental Health No. 9, Winter 2000 guest editorial Befriending Demons: Healing Across Cultures

magine a Native Am- was done through a hospi- Dr. Terry erican anthropologist Trained as a traditional Native tal interpreter. Tafoya Iworking on his PhD by American Storyteller, Dr. Tafoya documenting the healing is a Taos Pueblo and Warm I began by telling her a tra- ceremonies of a major North Springs Indian who has used ditional story from the Pacif- American hospital. He comes American Indian ritual and ic Northwest. The story tells in at his convenience and ceremony in his work as a Fam- of a cannibal woman who observes a man in white, ily Therapist while serving as steals young children, decorated with colourful Clinical Faculty and Senior Staff whisking them away in an writing utensils in a pocket for the University of Washing- enormous basket she carri- and a shiny medallion hang- ton’s School of Medicine. He ers on her back. Eventually ing from a narrow rubber has worked extensively in Can- the young hero of the story tube that he will periodical- ada, Mexico and Europe, train- outsmarts her and mobiliz- ly place on the chest of his ing mental health professionals es the other kidnapped chil- patients to make them well. and educators in the areas of dren to push her into a fire, He draws strange designs on transcultural concerns and where her ashes fly up and a small square of white pa- bilingual education. He is presently a Visiting Professor in the De- become mosquitoes. (Which, per that he will give patients partment of Applied Human Science at Concordia University in of course, is why mosquitoes to take with them. Because Montreal. He also acts as an Adjunct Professor of Educational Policy bite even today.) the anthropologist does not Studies at the University of Alberta. fully understand the bio- The story is one I frequently medical culture, and is not use with suicidal patients, spending twenty-four hours whether they worked on traditional healer, or Twati since their problems paral- of every day in contact with other North American Indi- can adjust actions to meet lel the structure of the leg- the man in the white coat, an people, or on non-Indi- the needs of his or her pa- end: their problems are he will make a number of ans, they would not treat all tient. Some people seeking devouring them alive, and errors in understanding the people the same, even if the healing come as a last resort the story provides the frame structure of healing. symptoms were the same. In- to a Twati or a surgeon, some for understanding that with deed, some of the prelimi- will come with complete appropriate action, trouble A serious mistake would be nary activities, like cleaning confidence that this is what won’t disappear, but will to assume that anyone who and purification, would be has to be done, while others transform into something comes in with a similar the same, but the actual will come in terror, uncer- that can be dealt with. Be- symptom would obtain a healing actions are different. tain of what might happen fore the story was half-told, similar treatment. But in re- A comparison would be to a during the healing process she had calmed down, and ality, the treatments are medical doctor who will or if the healing is success- was quietly listening. not the same — not all pa- “scrub up” in the same man- ful. How can both groups be tients will receive a type A ner, even though he or she treated in exactly the same I then conducted a cleansing blood transfusion; not every- might be performing a vari- way? ceremony for her, modified one with an infection will be ety of operations. to reflect her Southeast Asian given penicillin. I would like to present an heritage. Through the trans- In the traditional training of example of how a tradition- lator I gave a detailed expla- Unfortunately a great deal the Walsakasla, or Storytell- al purification ceremony nation of the ceremony, of information on healing er (a related field to Heal- was modified in the treat- discussing the spirit body of ceremonies of other cultures ing), a story is told four ment of a Cambodian wom- each human which extends suffers from this problem: times. The fifth time, the ne- an. She had been admitted to approximately one and one conclusions are based on an ophyte Storyteller must tell a major county hospital, half inches beyond the phys- outsider’s direct observation the story verbatim: to fail to feeling she had been pos- ical body. Harmful thoughts of a limited number of in- do so would result in a beat- sessed by evil spirits. She had — anger, greed, or hate — 3 teractions looking for a ing. But if the new Storytell- also been diagnosed as ano- result in a spiritual pollution structure and technique of er is successful, then he or rexic and spoke little if any which attaches to the spirit intervention. In watching she can “alter” the story to English, and came into the body and must be directly my relatives heal in our make it appropriate for a treatment room almost hys- removed through various traditional approaches, specific audience. Just so, the terical. My work with her techniques; I use an eagle Visions: BC’s Mental Health Journal Cross Cultural Mental Health No. 9, Winter 2000 glossary of key terms

feather. Around her were psychiatrists and Adapted from “The Terminology of Diversity” psychiatric nurses from her ward who Edited by Sandy Berman and Mary Anne-McInnes, drummed for me. Multicultural Change in Health Services Delivery. Vancouver, 1995. While many Native American ceremonies have four elements, a number of Asian cul- Cross Cultural means moving from one’s culture to another. This may refer to communication tures stress five elements, expanding to in- (exchanging information or ideas) between individuals coming from different cultural backgrounds. clude metal. For that reason I altered the ceremony to include five elements. For exam- Cultural Sensitivity is the awareness of one’s own cultural assumptions, biases, behaviours, and ple, I burned incense of sweetgrass and sage beliefs and the knowledge and skills to interact with people from other cultures without imposing in a large abalone shell. This combined fire one’s own cultural values on them. Cultural sensitivity is required at individual, professional, and (the burning), air (the cloud of incense), wa- organizational levels. ter (the sea shell), earth (the red paint and the plants used for the incense), and metal Culture (noun) refers to the patterns of learned behaviors and values that are shared among mem- (used to light the incense). While I don’t think bers of a group, are transmitted to group members over time, and are often used to distinguish the it’s necessary for patients to understand all members of one group from another. Culture can include ethnicity, language, religious and spiritual the details of treatment for it to be effective, I beliefs, ethnicity, gender, socio-economic class, age, sexual orientation, geographical origin, group believe having a framework for making sense history, education and upbringing, and life experiences. of what is going on serves to strengthen the ceremony. Diversity is a broad term used to reflect the unique characteristics of us all. Its components include race, colour, ethnicity, ancestry, place of origin, age, gender, sexual orientation, physical and mental While “brushing” her with the eagle feather, abilities/qualities, socioeconomic status/class, education, language, family and marital status, reli- I felt a blockage around her abdominal area, gious beliefs, and criminal background. and suggested she alter her eating program from the standard three meals a day to five Ethnicity is, like race, a social and political construct used by individuals and communities to define (number sound familiar?) smaller ones. This themselves and others. Ethnicity tends to be based on a common culture, language, or nationhood. again addressed the problem of not eating properly by altering her pattern of eating Ethnocultural Group is a group of people who share common distinctive ethnicity, heritage, culture, while not telling her to increase her food in- language, social patterns, and sense of belonging. take. (I should mention that I had made some minor additions in the legend to provide em- Inclusive Organizations understand, accept, and respect all aspects of diversity. They involve peo- bedded commands for increased appetite.) ple who reflect the diverse groups in their community in the development of policies, services, and programs which are appropriate and relevant to them. An inclusive organization respects differences Having finished the brushing, I provided her and pays attention to the dynamics of difference. It does continuous self-assessment, expands cul- with a small prayer stick of eagle and parrot tural knowledge and resources, and adapts its service models to accommodate needs. Such organ- feathers tied with sage and sweetgrass. She was izations consult with diverse communities and are committed to hiring open-minded employees. instructed to keep this in her bedroom where she had previously had the nightmares that Multicultural Organizational Change This term refers both to the process of dismantling visible and triggered her fears of possession. I intended invisible barriers to full participation of all people in a community — especially people from tradition- the strong fragrance of the sage and sweet- ally non-dominant groups — and the establishment of an organization reflective of, responsive, and grass to remind her of the cleansing ceremo- responsible to the entire community. ny, anchoring the sense of mastery and support. Racism is (1) any action or practice which denies equality to a person because of their race, religion, ethnicity or culture (=individual racism); (2) social and organizational structures including policies While this description singles out only some and practices which, whether intentionally or not, exclude, limit, and discriminate against individuals of the actions and explanations involved, I not part of the traditional dominant group (=systemic racism/discrimination); (3) a set of beliefs, hope it serves to illustrate the need to not be whether conscious or not, rooted in the superiority of one race over other races (=ideological racism). rigidly tied to only one way of dealing with people in need of help. There are different Stereotype is a false or generalized view of a group of people which results in the unconscious or methods of healing because there are differ- conscious categorization of each member of that group, without regard for individual differences. ent needs of people. Stereotyping may relate to race or age; ethnic, linguistic, religious, geographical or national groups; social, marital or family status; physical, developmental or mental attributes; and/or gender.

4 Tokenism is a process and action of involving an individual group member, primarily based on their membership to that group. It does not take into account individual differences or contributions. Some possible results of tokenism include (a) unspoken pressures placed on that individual to have input based on their group membership, (b) expectations that the individual will behave like “mainstream” group members while still representing their group, and (c) expectations that the individual will give evidence of the worthiness or unworthiness of their group.

Visions: BC’s Mental Health Journal Cross Cultural Mental Health No. 9, Winter 2000 PERSPECTIVES ON MENTAL HEALTH AND ILLNESS

Culture-specific “Of all the medical specialties, ... psychiatry has the most pervasive relationship to culture. Psychiatry is, to begin with, syndromes: a window on a culture’s sources of distress and on the human consequences of such distress.” (Kleinman, p. 183) It’s all relative

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123456 123456 feeling-myself”ness. Sarah Hamid ’m a living, Þ So whether a psycho- breathing ex- logical condition is attrib- I ample of the eth- ß biology, uted to the loss of one’s soul nic diversity of BC, medicine, and physical (see susto in Table 1), the indeed, Canada. Despite a have causes of human behaviour. loss of the vital essence of mixed Parsi and Afghan an- had in the Afghan one I But as Table 1 (pp. 7-8) semen (see dhat), the inter- Sarah Hamid cestry, two mother tongues could have grown up in, but hopefully illustrates, the ference of evil spirits or oth- is Visions’ before English, and a non- it comforts me nonetheless. medical model is not the er supernatural forces (see Production and Canadian birthplace, I have Her saying she doesn’t want only way to interpret a prob- bebainan, hsieh-ping, or Design Editor. been immersed in Canadian nazar to take place is a state- lem. Just like a native lan- zar), or problems with the In addition to society since the age of five ment of protection and luck, guage is a shorthand by heart (see narahatiye qalb), her Visions — almost as far back as my given almost in the same which people of a nation or the point is that each culture role, she will memory begins. spirit that “break a leg” is to culture can communicate has, in the course of its be taking a stage actor. with each other easily, so is unique evolution, come up on the job I’m also a living, breathing a locally understood way of with an interpretive tool its of Public example of a visibly ethnic Many people may think my talking about psychological citizens can accept and use Education individual with a mental ill- aunt’s way of interpreting problems a kind of short- with each other to describe Coordinator at ness. And like so many oth- my emotional distress is hand. It’s a point of entry for what’s wrong in the head, BC Division ers in this increasingly “folksy” or even “cute.” But talking about feeling out of heart, and body. in the new multicultural North Ameri- it’s not. In its own cultural sorts within one’s self. It’s a year. can continent of ours, I am context, it is not only just as metaphor a person in that In the wake of all the cul- in a unique position of hav- viable an explanation as culture knows he or she can tural awareness messages in ing access to at least two “major depressive disorder” use to express distress, ini- the ’90s, all of this may seem ways of interpreting the root is, but it is in fact more so tiate discussion, and negoti- like common sense. But the of my illness: the North because it has a meaning to ate help from the family or fact of the matter is the study American way, and an middle-easterners that the community. That metaphor of psychiatry in the Western “Asian” way. Western diagnosis just can’t carries a special power be- world still maintains a strong touch. cause it has instant meaning bias in favour of finding Lower Mainland clinicians in the system of understand- similarities rather than dif- have given me the label “ma- When I say “it’s all relative” ing the entire community ferences across cultures and jor depressive disorder.” in the title of this article, I shares. of uncovering “universals” However, whenever I make mean exactly that: describ- in mental disorder. Klein- progress with my medica- ing mental illness is relative My use of the word “meta- man says, “This bias should tions, my Afghan aunt tells to the culture that is inter- phor” here is not acciden- not surprise us. Much cross- me she essentially wishes preting that illness. I can’t tal. Anthropologists have cultural research in psychi- that no one should nazar even remove the Western identified a culturally-sen- atry has been initiated with me. That is, no one should bias that I’ve grown up with sitive way of talking about the desire to demonstrate give me the “evil eye,” long in writing this article. After culturally different types of that psychiatric disorder is thought of in Latino, Medi- all, calling mental illness an interpretations as “idioms of like any other disorder and terranean, and Islamic cul- “illness” at all (or “disorder” distress.” “Idiom” is anoth- therefore occurs in all soci- 5 tures as a main cause of or “disease” with “symp- er way of saying a culture- eties and can be detected if sickness and misfortune. My toms,” “diagnosis,” and specific metaphor or standardized diagnostic aunt’s statement doesn’t “treatment”) places a psy- symbol; “distress” covers the techniques are applied” (p. have the same power in my chological phenomenon feelings of pain, negative 18). Although the bio- Canadian home as it would firmly in the world of changes, and general “not- medical model of North Visions: BC’s Mental Health Journal Cross Cultural Mental Health No. 9, Winter 2000 perspectives on mental health and illness

America and Western Eu- than group-based society, sinfulness in the same sen- ethnocultural study for its rope has been certainly the Western concept of so- tence, but the bilingual re- own sake, not just as a means useful in managing a vast cial phobia typically sees a searchers realized each term to proving the universality of number of psychiatric person’s fear and anxiety as had distinctive meaning and mental disorder, do people symptoms, it may have being directed towards po- had to be separated out into stop becoming nails to the been pushed so far as to ob- tential criticism by others. three questions to get an biased eye of the hammer scure other models for inter- So, for instance, you obses- accurate response. The find- and start becoming people preting similar complaints. sively worry about your zip- ings would have had little again. per being down because you meaning without this reali- Kleinman and other cultur- are worried about being zation. al psychiatrists and medical laughed at. But in Japan’s anthropologists have gone taijin kyofusho, the focus is Kleinman notes that atten- on to argue that too much not on the self but rather on tion to culturally meaning- cross cultural psychiatric the embarrassment the indi- ful translation can yield research assumes that cul- vidual does not want to in- amazing findings. For exam- tural differences are a super- flict on others. It may be hard ple, a Vietnamese-language ficial “mask” — a layer that for us to understand that a depression scale for use with must be peeled away to re- person could worry about U.S. Vietnamese refugees veal the real, biological making someone else un- found “shameful and dis- “fact” underlying the disor- comfortable with virtually honored” but not “guilt” to der. The danger of this bias no thought of one’s own po- be important factors in dis- though is illustrated by the tential embarrassment, but it criminating depressed from ______old cliché “in the eyes of a is just this kind of subtle yet non-depressed Viet-Ameri- References hammer, everything looks significant nuance that cans. Further studies of why like a nail.” In the cross cul- Western psychiatrists need guilt is less a symptom of Cultural Conceptions of Mental Health and Therapy. (1982). A.J. tural psychiatry context, this to understand if they hope depression among Vietnam- Marsella & G.M. White (Eds.). Bos- saying warns that even if to serve a multicultural cli- ese than it is for Westerners ton, MA: D. Reidel. there are some universal entele made of such differ- could yield valuable insights Culture-bound syndromes, ethno- mental disorders, that ing worldviews. into stigma across cultures psychiatry, and alternate therapies. doesn’t mean there are only which could, in turn, spark (1976). W.P. Lebra (Ed.). Honolu- universal mental disorders In terms of research conse- further research into cultur- lu: University Press of Hawaii. with variations only in quences, poor understand- al conceptions of mental ill- Guarnaccia, P.J. & Rogler, L.H. name. When dealing with ing of the cultural contexts ness. (1999). “Research on culture- human culture, it is much of mental complaints does bound syndromes: New Direc- tions.” American Journal of more complex than that. not bode well for being Culture and ethnicity are Psychiatry, 156(9), 1322-1327. Biology and environment are sensitive to translation in part of our personhood. In- too intertwined. A failure to cross-cultural research. For dividuals who are living Hall, T.M. (1998). “Glossary of culture-bound syndromes.” understand this complexity example, “feeling blue” or with a mental illness neces- http://weber.ucsd.edu/~thall/ can lead to misdiagnosis and “feeling down” is a common sarily come up with their cbs_glos.html inaccurate research. idiom of distress in the Eng- own ideas of what’s going on Handbook of Culture and Mental lish language and can be inside them even before they Illness: An International Perspec- For an example of easy mis- useful in diagnosing depres- visit a clinician (if they do tive. (1995). I. Al-Issa (Ed.). Madi- diagnosis, taijin kyofusho, as sion when asked on written at all). And those ideas are son, CT: International Universities Press. explained briefly in Table 1 tests. However, a straight often shaped by one’s cultur- is a Japanese phobic reaction translation of this conversa- al background and the ways Kleinman, A. & Coven, A. “Psychia- associated with fear of oth- tional phrase would have no of understanding the world try’s Global Challenge.” Scientific American, 276(3), 86-89. ers in social situations. A meaning in non-Western with which one has grown Western psychiatrist unfa- languages. Only spending up. Any successful client- ---. Rethinking Psychiatry: From miliar with this disorder in time living in other cultures centred approaches to ther- Cultural Category to Personal Ex- perience. (1988). New York: The its native context might gloss could pinpoint the conver- apy have to mesh with the Free Press. over the entry in the table sational phrases used to talk individual’s own worldview. thinking it must be “just an- about various emotional Therefore, the only way to Pfeiffer, W.M. (1982). “Culture- bound syndromes.” In I. Al-Issa other name” for “social pho- states. suggest the best courses of (Ed.), Culture and Psychopatholo- bia.” However, there is an treatment action is to under- gy. Baltimore, MD: University Park 6 important difference in Ja- For another example, Klein- stand culture-specific “idi- Press. pan that a treatment ap- man relates the story of a test oms of distress” as well as The Culture-Bound Syndromes: proach based on the translated into Hopi, an the person’s own unique Folk illnesses of psychiatric and an- diagnosis “social phobia” American Indian language. take on those idioms. Only thropological interest. (1985). R.C. Simons & C.C. Hughes (Eds.). Edit- would not recognize. In our The screening test had con- when modern psychiatry ed by Ronald C. Simons and Charles individual-centred rather cepts of guilt, shame, and can embrace this kind of C. Hughes. Boston, MA: D. Reidel. Visions: BC’s Mental Health Journal Cross Cultural Mental Health No. 9, Winter 2000 perspectives on mental health and illness

TABLE 1: A Sampling of Conditions of Distress from Around Local name given Part of the world Defining features of the condition to the condition where it has meaning amok or meta elap Malaysia an episode characterized by a period of brooding (usually caused by what seems to the person to be an insult or betrayal) followed by a violent outburst. "anorexia mirabilis" Europe in medieval times very restricted eating patterns associated with the experience of religious devotion. or "holy anorexia" (around 476-1450 AD) Usually was not considered a serious problem within the culture (n.b.: terms are modern) anorexia nervosa North America, very restricted eating patterns associated with the fear of becoming overweight. Western Europe Sometimes combined with excessive exercise. See also bulimia nervosa. ataque de nervios Latin America, Latin literally means an "attack of nerves." Frequently occurs as a result of a stressful family Mediterranean groups, event like a death or divorce. Symptoms include uncontrollable shouting, attacks of Latin Caribbeans crying, trembling, heat in the chest rising to the head, and verbal or physical aggression. bah-tschi or bah-tsi Thailand similar to latah. or baah-ji bebainan Bali (Indonesia) onset of sudden illness attributed to the ill individual's soul being possessed by an evil spirit called bebai. Symptoms include emotional stress, confusion, hopelessness, and a cold feeling beginning in the legs and spreading to the rest of the body. bilis and colera Latin America physical or mental illness as a result of extreme emotion which upsets the balance of hot and cold in the body. Bilis and colera specifically point to anger as the cause of illness. boufée deliriante West Africa, Haiti sudden outburst of agitated and aggressive behaviour, confusion, and muscular excitement. Sometimes accompanied by paranoia or hallucinations. brain fag or brain fog West Africa experienced mainly by male high school or university students. Symptoms include difficulties concentrating, remembering, and thinking. Students often state their brains feel "fatigued." Pain, pressure, tightness, blurred vision, and/or the feeling of heat or burning are often felt in the head and neck regions. brujeria Latin America simila r to rootwork. bulimia nervosa North America, an extreme fear of being overweight. Strategy for preventing weight gain is not self- Western Europe induced starvation like anorexia nervosa but rather binge eating followed by self-induced vomiting or overuse of laxatives to "expel" food from body. cafard or cathard Polynesia similar to amok. dhat India semen-loss syndrome characterized by severe anxiety around the discharge of semen and general feelings of weakness or exhaustion. falling out or Southern U.S.A., Caribbean episodes characterized by sudden collapse either without warning or preceded by feelings blacking out of dizziness or "swimming" in the head. Person's eyes are usually open, but the person claims blindness. Also, the person hears and understands what is happening around him or her, but feels powerless to move. ghost sickness various American preoccupation with death and the dead, sometimes associated with witchcraft. Symptoms First Nations groups may include loss of appetite, nightmares, weakness, fear and anxiety, confusion, a sense of being suffocated, hopelessness, and fainting. grisi siknis Miskito Indians (Nicaragua) symptoms include headache, anxiety, anger, and aimless running. Some similarities to pibloktoq. hi-wa itck Mohave American Indians insomnia, depression, loss of appetite, and sometimes suicide associated with the unwanted separation from a loved one. hsieh-ping Taiwan a brief trance state during which a person is possessed by an ancestral ghost who often tries to communicate with other family members. Symptoms include shaking, confusion, and hallucinations. hwa-byung or Korea anger syndrome. Symptoms are attributed to the holding back of anger and may include wool-hwa-bung insomnia, panic, fear of impending death, indigestion, heart palpitations, and a feeling of a mass in the gut. iich'aa Navaho Indian similar to amok. imu parts of Japan similar to latah. involutional Spain, Germany paranoid disorder occurring in midlife. paraphrenia 7 irarata Me ru tribe of Northern severe reactionary depression which usually affects menopausal women who have lost Tanzania a spouse; often results in death from loss of appetite and thus loss of body weight. jinjinia bemar Assam (India) see koro. jiryan India similar to dhat. Visions: BC’s Mental Health Journal Cross Cultural Mental Health No. 9, Winter 2000 perspectives on mental health and illness

koro Malaysia sudden and intense anxiety that the penis will recede into the body and possibly cause death. See suo yang, jinjinia bemar, and rok-joo. latah Malaysia, Indonesia a hypersensitivity to fright often in a trance-like state. locura Latin America a severe form of chronic psychosis (i.e., where a person's personality becomes disorganized or confused and his or her reality highly changed). It is attributed in the culture to an inherited vulnerability, the effect of many life difficulties, or a combina tion of the two. mal de ojo Spain, Latin America the Spanish term for "the evil eye." Evil eye occurs as a common metaphor for disease, misfortune, or social disruption throughout the Mediterranean, Latin American, and Muslim worlds. mal de pelea Puerto Rico similar to amok. mali-mali or silok Philippines similar to latah. mal puesto Latin America similar to rootwork. narahatiye qalb Iran, other Middle Eastern heart distress. Characterized by a physical sensation of the heart pounding, quivering, countries or feeling squeezed along with other symptoms of anxiety. Is closely associated with feelings of sadness or being trapped. nazar Islamic nations see mal de ojo. nervios Latin America refers to a general state of vulnerability to stressful life experiences and to a syndrome brought on by these stresses. Symptoms can be very broad but often include emotional distress, headaches, sleep disturbances, nervousness, and difficulty concentrating. nevra Greece similar to nervios. pibloktoq or Greenland Eskimos an abrupt psychotic state with extreme excitement and often followed by seizures and Arctic hysteria coma lasting up to 12 hours. The individual performs unusual, irrational, or dangerous acts during the episode but will usually report not being able to remember any behaviour after the attack has passed. This condition is found throughout the arctic region with local names. qi-gong China a time-limited episode characterized by paranoid and other psychotic symptoms. Can psychotic reaction occur after participating in the Chinese folk health-enhancing practice qi-gong. rok-joo Thailand see koro. rootwork Southern U.S.A., Caribbean illness explained as the result of hexing, witchcraft, voodoo, or the influence of an evil person. sangue dormido Portuguese Cape Verdeans literally means "sleeping blood." Symptoms include pain, numbness, shaking, convulsions, blindness, heart attack, infection, stroke, and miscarriage. shenjian shuairuo China symptoms may include physical and mental fatigue, headaches, difficulty concentrating, sleep disturbance, sexual dysfunction, anxiety or irritability, and memory loss. shenkui China anxiety or panic symptoms accompanied by bodily complaints for which no physical cause can be found. Symptoms attributed to semen loss. Similar to dhat, jiryan, and sukra prameha. shin-byung Korea anxiety or panic symptoms accompanied by various bodily complaints and followed by possession by ancestral spirits. shinkeishitsu Japan marked by obsessions, perfectionism, social withdrawal, and irrational fears of being ill. spell Southern U.S.A. a trance state in which individuals communicate with deceased relatives or spirits. Are not considered medical problems in the culture but can often be misunderstood as "psychotic episodes" by clinicians. sukra prameha Sri Lanka similar to dhat. suo yang or shuk yang China see koro. susto Latinos in North America an illness attributed to a frightening event that causes the soul to leave the body, and Latin America leading to symptoms of unhappiness and sickness. Alternate names include espanto, pasmo, tripa ida, perdida del alma, and chibih. tabanka Trinidad depression associated with a high rate of suicide. Seen in men abandoned by their wives. 88 taijin kyofusho Japan a syndrome of intense fear that one's body, body parts, or bodily functions are displeasing, embarrassing, or offensive to other people. zar Ethiopia, Somalia, Egypt, experience of spirit possession. The person often acts totally unlike him or herself with Sudan, Iran, and elsewhere in symptoms including laughing, shouting, hitting the head against a wall, singing, or North Africa and Mid-East weeping. Special thanks to T. Hall’s comprehensive “Glossary of Culture-Bound Syndromes” [http://weber.ucsd.edu/~thall/cbs_glos.html] for much of the material in this table. Visions: BC’s Mental Health Journal Cross Cultural Mental Health No. 9, Winter 2000 perspectives on mental health and illness How Does Stigma Present Itself in Different Cultural Communities?

tive communities is kind of I’m talking about severe new and we’re accepting the mental illness, more around fact that some of our mem- schizophrenia. The BC Resource Centre for the Elimination of Stigma bers have mental illness, and we’re trying to educate This article is proudly tigma about mental ourselves, but it’s long hard Stigma and Mental supported by CMHA, BC illness is still highly work, but that’s where Division’s anti-stigma Illness in the SSSprevalent in North funds for education would Vietnamese Culture campaign OPEN MIND American society. Visions come in — to have that (based on Nova Scotia asked the Multicultural domino effect. Cho Van Le Cho Van Le is Division’s program). Mental Health Liaison work- the Southeast ers of the Greater Vancou- It’s shame-based kinds of he Vietnamese commu- Asian Mental ver Mental Health Service to stuff. We never know what’s Tnity has been in Vancou- Health Liaison describe views about mental next: tuberculosis, diabetes, ver, BC for the past 24 years, Worker for the illness and manifestations of Fetal Alcohol Syndrome. but as of today, Vietnamese Greater stigma in their own commu- These are all issues that are patients have still under- Vancouver nities. Most provided sug- floating around our commu- utilized the Canadian men- Mental Health gestions on what can be done nities all the time, and it’s so tal health services, due to Service, based at to counter this stigma. difficult. There’s all kinds of one predominant reason: the Kitsilano negative stigmas that we “STIGMA”. Mental Health have already, so native peo- Team. ple aren’t too open to have The notion of mental illness Stigma and the First mental illness [on top of the is quite dreadful to the Viet- Nations Community others]. namese people, who believe Perry Omeasoo that once a person contracts Perry Omeasoo I remember about ten years mental illness there is a very (pronounced here’s been so many neg- ago HIV hit the Native pop- remote chance of recovery. O-me-a-sue) is Tative stigmas around the ulation and as a result peo- Along the way the person the First Nations native communities such as ple were running scared, also brings shame and dis- Mental Health alcohol, substance abuse, the and Native communities grace to the family due to, as Liaison Worker natives at Musqueam, the were ostracizing people with culturally believed, possible for the Greater Nisga’a Treaty. People in the HIV, and I think today, by bad deeds in a past life — Vancouver Mental white community look down providing education about even though nothing was Health Service, and frown upon all these HIV and how it’s not going done wrong in the present. based at the things ... so we have so many to be transmitted by holding Strathcona Team. stigmas, we’re not about to hands [things are better]… The individual, believing This excerpt is jump up and say “Oh, we that he or she will bring from our feature have mental illness too.” I think the whole education- shame and disgrace to the interview (pp. 19- al process has to be done for family, automatically forms 22 of this issue). And historically, when a Na- mental illness, and maybe a strong internal stigma. tive person got diagnosed my children will look at Stigma due to misconcep- with mental illness, every- someone with mental illness tions of mental illness im- body made sure he didn’t as somebody we don’t have poses a bitter burden that have a substance-use issue, to be ashamed of, and some- ruins the person’s life and and he would be shipped to thing that’s just accepted and relationships with others, a substance program and the part of our community, and because the individual mental illness would be left not something we asked for, rarely maintains a healthy behind. You know Native or something we got because self-image and instead man- 9 people drink sometimes to our grandparents went to ifests in his or her life what- try to forget they have a residential school, or be- ever he or she expects at the mental illness; it came first. cause our parents beat us. deepest level. Mental illness is a disease So mental illness around na- that just happens, and The mental illness, which is Visions: BC’s Mental Health Journal Cross Cultural Mental Health No. 9, Winter 2000 perspectives on mental health and illness

impossible to disclose to oth- illness by its name. People Because many individuals in Related Resources ers, turns the Vietnamese feel less stigmatized when the community have a his- patient’s life into a meaning- they can name their illness tory of severe trauma, the „ Reducing Stigma about less and lonely existence. and when they can say that issue of trust is very relevant Mental Illness in they suffer from depression, when they seek individual Transcultural Settings: A an anxiety disorder, or schiz- and/or group therapy. Guide. Australian ophrenia rather than saying Transcultural Mental Health Stigmatized Views Network. of Mental Illness in that they have “a mental ill- the Latin American ness.” They accept very well Mental Disorder and „ Rooney, R. & K. O’Neil. the biological explanation of “Investigation of Stigma and Community Stigma in the South Mental Illness Amongst non- mental illnesses as we un- Asian Community Norma Sanchez Norma Sanchez, MD derstand them today. With- English Speaking Background Communities & is the Latin out proper education about Kala Singh, MBBS Development of Approaches American atin American people, in the illness, individuals and to its Reduction.” Australian Mental Health L general, are very open to families tend to isolate them- n the South Asian commu- Transcultural Mental Health Liaison Worker seeking help for themselves, selves from sources of sup- Inity, mental disorder, in Network web site: http:// for the Greater a family member, or a friend, port because of the stigma. the past and even now by ariel.ucs.unimelb.edu.au/ atmhn/www/research/ Vancouver when they “do not feel well.” some, is considered to be a stigma1.html Mental Health In general, there is less stig- form of punishment by God Service, based But in spite of this openness ma in seeing a counselor or or possession by demons or at the Mt. in the Latin American com- a psychologist than in seeing evil spirits. If a child is born Pleasant Mental munity, which is a very di- a psychiatrist. For some peo- with mental retardation or Health Team. verse and heterogeneous ple, the hesitation about see- a physical defect, it is con- Kala Singh is the South Asian community, there is, as in ing a psychiatrist who does sidered that God has pun- community Mental Health other communities, some not speak Spanish stems ished the child and the Liaison Worker for the Great- stigma about mental illness from the fear that the pro- family for deeds in a previ- er Vancouver Mental Health or seeing a psychiatrist. fessional might not under- ous life. Service, South Team. stand their cultural beliefs When they can access men- and values. This is sometimes Mental disorder in an adult tal health service providers much more evident when was (and is still considered ple are becoming aware of who speak their language, parents have to seek help for by some) to be possession by mental disorder, more cli- they do so with little hesita- their children. They fear that demons or evil spirits. Ritu- ents are being brought to the tion. For this reason, Latin they themselves or their als to please God and exor- attention of mental health American people show the child-rearing practices will cism were practiced. A workers as a first choice. highest rate of service utili- be blamed for the child’s mental health worker was This shows that stigma at- zation among the Greater problem. They also fear that consulted only as a second tached to mental disorder is Vancouver Mental Health their parental authority choice, when these rituals decreasing but more is need- Service’s clientele. could be undermined by a failed. In some cases these ed to educate the communi- professional who does not rituals serve as a form of ty through pamphlets, Stigma is greatly reduced by understand the family cul- psychotherapy and are help- newspaper articles, radio, education and by calling the tural background. ful. As more and more peo- and television talk shows.

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Visions: BC’s Mental Health Journal Cross Cultural Mental Health No. 9, Winter 2000 perspectives on mental health and illness

diagnosed with mental illness, it is often more therapeutically effective to seek a Sophia Woo treatment alliance with those family members who are influential r e a and those who are closest to c that person. By understanding h t the dynamics of the hierarchi- Sophia Woo is l a cal system within that partic- the Chinese e ular family, a therapist is able h community Chinese Culture to provide a holistic treatment Mental Health l approach. Liaison Worker a t for the Greater n and Mental Health Chinese family members are Vancouver e usually less verbal in express- Mental Health m ing their affections and feel- Service, based at ings. Many may choose to the Grandview- anada today is home to increasingly diverse cultures. show their concern in concrete and indirect ways, or through Woodlands The demographic profiles have changed from pre- subtle actions. For example, they will bring food to their loved Mental Health Cdominantly European to a rich, cultural mosaic. There ones in hospitals and group homes, or will provide continu- Team. are at least eighty cultural groups and more than one hun- al financial support to an adult child with mental illness. dred languages spoken by the various ethnic groups in Can- When a professional makes family assessments, it is impor- ada. Approximately 30% of the population in the Greater tant to take into consideration family closeness from the per- Vancouver area is of Chinese origin. spectives of the Chinese culture.

These changes give rise to special issues that concern mental Chinese families often think they are accountable and re- health and health care professionals. Ethnocultural groups sponsible for their family members with mental illness. Their are found to be under-utilizing existing mental health and tolerance for inappropriate behaviours is relatively high social services. One possible interpretation is that new im- when compared to Western cultures. They usually have in- migrants do have unique experiences and needs which re- ternal ways of dealing with problems. It is not uncommon quire particular attention and care. for parents to provide refuge to their adult child with men- tal illness, and many will stay under the same roof. Remov- On the other hand, it is challenging as well as rewarding for ing a mentally ill person from his or her family is often perceived mental health care professionals to discover and understand as a failure or loss of control by the family. However, when an the beliefs, values, and health practices of various cultures, individual with mental illness is exhibiting chaotic behav- and to provide culturally sensitive and appropriate health iours which uproot the family, health care professionals must care and counseling services for ethnocultural clients and intervene patiently to explain and negotiate alternative ar- their family members. rangements such as group homes or supervised semi-inde- pendent living programs before the problems become When we work with Chinese clients, we have to treat each insurmountable. of them as individuals rather than as a homogenous group. We have to take into account their immigration pattern, the While the Westernized Canadian-born Chinese may adopt social structure of their environment, their education, and Western health care practices, the Chinese-speaking, first- their economic background. We also have to consider their generation immigrants tend to incorporate traditional country of origin (whether they are from Mainland China, Chinese health beliefs and practices. For example, it is com- Taiwan, Hong Kong, Southeast Asia, or even Latin America). mon among Chinese to understand that illness is caused by There are cultural differences among these countries. Last an imbalance of yin and yang, a condition often triggered by but not least, we have to consider their immigration status: the types of food one ingests. Certain types of food, such as whether they are independent or sponsored, permanent or raw vegetables, cold drinks, watermelons, and bananas are temporary residents, and whether they are immigrants or perceived as “yin” (cold) foods. Others such as deep-fried refugees. Adaptation and acculturation are also influenced food, chili and curry are perceived as “yang” (hot) foods, by the length of time in their new country and by their whereas ducks, geese, and shellfishes, which may cause al- familiarity with its cultural characteristics, customs, and lergic reactions to some, are perceived as “poisonous”. An health beliefs. elder will appreciate a cup of warm water more than a glass of cold water fresh from the fountain. A mother may not The Chinese family system is patriarchal. Seniority and age, allow her children to drink pop when offered, particularly 11 position and gender determine power and respect within when they have asthma or any type of respiratory condition. the generations. Financial status and one’s ability to speak English can enhance power bases of certain family members Certain Chinese health concepts could be a hindrance to within the immigrant families; this is particularly relevant treatment plans and procedures. For example, some Chinese in North America. When a person of Chinese origin is are reluctant to have blood tests because blood is considered Visions: BC’s Mental Health Journal Cross Cultural Mental Health No. 9, Winter 2000 perspectives on mental health and illness

a “vital” agent and one’s vitality may be diminished when it is and our ethnic communities. It is psychologically comforting taken out of the body. Others are reluctant to take Western for Chinese people, just as it is for many to listen to old Chinese medications because they are perceived as potentially addic- songs, to have a cup of Chinese tea, or to eat tive and upsetting to the body’s homeostasis, particularly med- Chinese food. ications that carry side effects like constipation or any other type of digestive distress. Education and communication can facilitate treatment. The Greater Vancouver Mental Health Service has produced four- While most Chinese will seek Western medicine for acute teen brochures in Chinese and several videotapes on various illnesses such as appendicitis, gallstones, tuberculosis, and types of mental illness and mental health services in the com- even acute phases of mental illness, many will turn to Chi- munity. We also conduct an annual Cantonese Conference nese formulary or herbal medicines to treat chronic condi- on Mental Health and Mental Illness. In the spring of 1993, tions such as persisting cough, common cold, hypertension, the Northeast Mental Health Team embarked on culturally insomnia, and a lack of appetite. Some Chinese may seek specific family psychoeducation support groups. The Can- cures from substances which they identify as boosters to their tonese Family Support Group, which is psychoeducational own deficiency. For example, some Chinese parents may serve in orientation and began in 1993, is held on every second cow or pig brains to their school children, believing that this Wednesday of the month. will help boost memory and intelligence. Walnut is another favorite brain tonic because of its striking resemblance to The responses from families have been very positive. Due to the brain. Others with anemia may consume foods with red the demand for more support for family members, a Can- color such as red beans and red grapes. tonese-speaking satellite group (for family members only) was started in the summer of 1996, running every fourth While a lot of Chinese health concepts are not exactly scien- Wednesday of the month. A Mandarin psychoeducation tifically-based, many are results of generations of experi- group was begun in the spring of 1999, again backed by ences and are to the culture what grain is to wood. We all demands for education on mental health issues in Manda- have a need to connect with our roots, our social network, rin. This group runs the first Wednesday of every month.

Early Intervention and Cross Cultural Mental Health

Eric vidence is growing that standing of these factors is tal illness in its earlier stag- tures. In the absence of in- Macnaughton the earlier one inter- necessary for intervening es. Help sought in emer- formation, the tendency to Evenes, the better the earlier and more effectively gency situations can be es- “normalize” early signs of outcome will be for a young for all young people with pecially hard to come by, as mental illness, for example person with a major mental mental illness, regardless of local emergency wards often to explain them in relation illness such as schizophre- their background. lack specialist expertise and to certain spiritual tradi- nia. On the other hand, the hold a very high threshold tions, may be higher. Educa- Eric longer it takes to get help, the First of all, let us consider the for admission. tional resources must be Macnaughton is poorer the person’s response range of factors that contrib- sensitive to the explanations the Coordinator to medication, the chances ute, in general, to these Again, it is likely that these offered by diverse cultures of Policy & Re- of having a relapse grow, delays. Lack of accurate in- barriers are more trouble- and be able to promote ac- search at CMHA and the more disrupted the formation makes it difficult some for a person or family commodation between dif- BC Division. He person’s relationships and for the person and his or her from an ethnocultural mi- ferent understandings of the is the author of life plans become. The extent family to interpret early nority group. Public educa- illness experience. the BC Early of delays in “mainstream” problems as being due to tion about the early signs of Intervention society is surprisingly high: “mental illness.” If the fam- illness is usually not tailored A recent Australian report Study. typically around one year ily does suspect that “some- to culturally diverse audi- suggests that stigma is con- elapses after the first psy- thing is not right,” fear and ences. Cultural communities siderably stronger within chotic symptoms to the point stigma often prevent them may vary in their openness recent immigrant groups, 12 when care is received. This from taking steps to get help. to information. This, in turn, and that this was a main rea- occurs for a number of rea- When they do seek help, pri- may depend on the extent to son people did not reach out sons which, as this article mary care “gatekeepers” which there are persons or for help. Fear of stigma may will discuss, are likely more (e.g., school counselors, fam- agencies in a position to act be particularly great for cul- pressing in ethnocultural ily doctors, etc.) themselves as brokers between main- tures who lack understand- minority groups. An under- have trouble detecting men- stream and minority cul- ing about confidentiality, Visions: BC’s Mental Health Journal Cross Cultural Mental Health No. 9, Winter 2000 perspectives on mental health and illness

and believe their problems ed, due to a tendency to de- competence” of the treat- will become publicly known. fine mental health problems ment setting, as discussed in Sensitivity to stigma was also in terms of bodily com- other articles in this journal. a main reason why agency plaints (known as “so- people consulted in the Aus- matization”), rather than in To summarize, intervening tralian study were reluctant psychological or mental in a timely and effective to refer people on to special- terms. While this phenome- manner depends on public ist services. Negative percep- non is quite common across education, appropriate to

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123456 mental health care was as- health problems will be pre- ious forms across cultures. sociated with being “locked sented solely in terms of Next, our gatekeepers must up for life” or put to death. physical complaints. Lack of have the skills and resourc- These views may also have awareness by mainstream es to correctly identify and à been shaped by hearing practitioners and lack of ap- refer potential problems. accounts from other propriate assessment tools Connection to specialist re- recent immigrants of decreases the chances of de- sources also depends on negative experiences in tection and appropriate re- close coordination between the host country. A ferral to specialist services. the formal mental health study done in Montreal system and agencies or per- among the Filipino, There are many other barri- sons who can act as “culture Anglo-Carribbean, ers preventing access to care brokers.” Finally, successful

and Vietnamese com- which affect people from engagement and care, lead-

munities showed that in ethnocultural minorities to a ing to recovery, depends on ” addition to fear and stig- greater extent. Language and a non-traumatic, culturally ma, the other significant communication problems competent environment of barrier to help-seeking are obvious barriers, along care, and comprehensive The earlier one was the belief that serv- with lack of adequate cul- community support. intervenes, the ices would not be sensitive tural interpretation services. better the outcome to their cultural needs. Refugee claimants may be will be for a young reluctant to seek out help for will be for a young Vancouver- and Toronto- fear of deportation. In BC, ______References person with a major based studies have pointed to service mandates often re- mental illness. other delaying factors, such strict care to the “seriously Kirmeyer, L. et al. (1999). Pathways as a fear by Chinese families mentally ill.” Under this and Barriers to Mental Health Care Unfortunately, in an Urban Multicultural Milieu. delays are that an acknowledged men- mandate, services often do Culture & Mental Health Research surprisingly high, tal illness will affect the mar- not reflect the unique needs Unit, Report No. 6 (Part 1). surprisingly high, riage prospects of siblings. of refugees dealing with (address: www.mcgill.ca/Psychia- reasons behind try/transcultural/transcult.html - Poor coordination between trauma, for example, or im- follow links to Culture & Mental which are likely formal mental health serv- migrants dealing with psy- Health Research Unit) ices and cultural agencies chosocial problems relating more pressing Luntz, J. (1999). Report on the Us- in ethnocultural has also been identified as a to adapting to an alien or age of Child & Adolescent Mental minority groups. factor. The Montreal study unfriendly environment. Health Services by non-English minority groups. further illustrated that seek- Speaking Backgrounds: Executive Summary. Australian Trancultural ing help from culturally Access to care is not the only Mental Health Network. (address: ” appropriate alternatives de- issue related to effective early http://ariel.ucs.unimelb.au/atm- layed access to formal serv- intervention. Successful hn/www/research/stigma1.htlml) ices, but did not replace the engagement in care depends Macnaughton, E. (1999). The BC need for them. People who on a non-traumatizing and Early Intervention Study. Canadian were higher users of alter- effective initial experience Mental Health Association, BC Di- vision. natives eventually made high with admission and treat- use of formal mental health ment. It also requires help Rogler, L. & Cortes, D. (1993). “Help services. for the person and the fami- Seeking Pathways: A Unifying Con- 13 cept in Mental Health Care.” Amer- ly in understanding and ican Journal of Psychiatry 150(4), When people do access help coming to terms with the ill- 554-561. from formal services, they ness. These issues relate to St. Denis, V. (1997). “Shining a Light face problems having their the treatment environment, on Mental Health Treatment.” problem correctly interpret- but also to the “cultural Schizophrenia Digest, 14-15. Visions: BC’s Mental Health Journal Cross Cultural Mental Health No. 9, Winter 2000 CULTURAL COMPETENCE FOR PROVIDERS Cultural Competence and ‘The Knowledge Resource Base’

Eric he “Framework for cal model, but should in- conference identified a ial order rather than Macnaughton Support” is the con- clude experiential knowl- number of Western assump- independence; in this T ceptual basis guiding edge gained from the person tions about the way “mental context, Western ideas of the activities of the CMHA. with the illness and his or health” is conceptualized, therapy which are based The “Community Resource her family. More relevant to which would not be shared on working through Eric Base,” in turn, is a key con- the issue at hand, it also across cultures, for instance: one’s own personal his- Macnaughton is cept underlying The Frame- should include concepts of tory may be inappropri- the Coordinator work. It outlines a range of mental health or illness „ separation of mind and ate and ineffective. of Policy & possible resources in addi- that come from different brain and the brain/ Research at tion to the formal system cultural traditions. body: in contrast to the Another area of difference to CMHA BC which can provide support Western psychological consider is in the way men- Division. to a person with mental ill- Without a fuller knowledge methods which look at tal distress and illness are ness. These include self-help base, the potential of our “the mind” independ- experienced and expressed. and peer support; support efforts to promote recovery ently, techniques based Factors to consider include from family and friends; will be significantly hin- on Eastern traditions the following facts: from “generic” community dered. At the same time, such as meditation, tai resources, such as the these other sources of chi, Ayurvedic breath- „ stress and distress are knowl- ing, in fact, have positive culturally relative: dis- edge rep- benefits on the mind by tress may be experienced resent a concentrating on aspects and expressed differently wealth of of “physical” being depending on the cultur- potential such as posture and al background of the ideas. To breathing. individual, and since move for- mental distress is often ward, the „ separation of “illness” expressed as bodily com- “New and “health”; equating plaints in non-Western Frame- mental health with cultures, our assessment work for “control”: in contrast, instruments must reflect Support” ideas about wellness in and be sensitive to these recom- non-Western cultures differences; to take an- mends a tend to be more holistic, other example, while in two- and concentrate on bal- the West we assume the pronged ance or harmony (be- most extreme expression YMCA, the community cen- course of action. The first tween bodily elements, of depression, suicide, is tre, or local religious and task is documenting differ- or between the body and more common in men, cultural institutions; and fi- ent experiential and cultur- one’s environnment) recent evidence suggests nally from the formal system al understandings while at rather than on control that this does not hold itself, with respect to acute the same time becoming over the environment. true cross culturally. care, crisis services, or on- more aware of the assump- going community support. tions underlying the Western „ belief in and valuing of „ mental distress and biomedical model. The an independent “self”: interpersonal difficul- A concept which goes hand next undertaking is then whereas Western psy- ties often reflect social in hand with the Communi- promoting dialogue, doing chology equates mental factors related to the ty Resource Base, “The professional education, and health with “self-actual- immigrant experience Knowledge Resource Base” is influencing policy makers. ization” (moving to- rather than an underly- outlined in “The New wards independence), ing “disorder”: mental Framework for Support” With these tasks in mind, and labels strong family health professionals, 14 (Trainor, Pomeroy & Pape, what then can we say about bonds as “enmeshment” therefore, must be sen- 1993). The idea here is that the assumptions and knowl- (i.e. overly attached), sitive to the emotional the knowledge we use to in- edge base of the Western tra- other cultures value fa- stages often associated form our efforts to provide dition, in relation to other milial interdependence, with the immigrant ex- support should not be limit- points of view? A recent and decision making re- perience, from initial ed to the Western biomedi- cross cultural mental health flects respect for famil- elation related to high

Visions: BC’s Mental Health Journal Cross Cultural Mental Health No. 9, Winter 2000 cultural competence for providers

expectations, to disen- Girolamo (1995) relates chantment, to a balanced evidence that view which reflects both „ long-term outcomes of the strengths and weak- schizophrenia appear nesses of the host coun- more favourable in devel- try. In the context of the oping nations, probably immigrant experience, due to increased oppor- distress or interpersonal tunities for social inclu- conflict can be associat- sion in economies not yet ed, among other things, highly industrialized. with culture shock, un- „ incidence of mental ill- friendly reception in the ness is rising in the host country, unfamiliar developing world, as in- social rules, drops in sta- dustrialization proceeds. tus due to changes in oc- „ in Western countries, for cupational and social complex reasons, inci- roles, and changes with- dence of schizophrenia in familial roles. may increase in second- generation immigrants. „ “symptoms” of appar- „ finally, according to a re- ent mental illness may view by Beiser, response reflect the immigrant or to medications varies visible minority experi- culturally. ence rather than simply an underlying illness: There are doubtless many for refugees, what ap- other areas of knowledge pear to be psychotic and practice that will symptoms can be disso- require revision when con- Related Resources on Cultural Competence ciative symptoms related sidered in cross cultural to post-traumatic stress perspective. A thorough „ Cultural Competence Assessment Tools. Boulder, CO: Western Interstate disorder; similarly, par- reevaluation of the Western Commission on Higher Education. (Report: 97 pages, 1996). anoia may not be patho- knowledge base, along with Included as an appendix in the Western Interstate Commission on Higher logical, but instead careful evaluation of reha- Education’s 1996 report “Developing Culturally Competent Systems of Care for reflective of political bilitative alternatives from State Mental Health Services,” these assessment tools were designed for various conditions in the coun- all areas of the “Knowledge stakeholders working with mental health and cultural competence. This report try of origin, or racism Resource Base” can only im- includes a patient satisfaction survey containing suggested modifications; a service provider version of a cultural competence self-assessment questionnaire; in the host country. prove the “cultural compe- clinical performance assessment; cultural competence assessment instrument tence” of our mental health focusing on organizational environment, public relations, community work, human „ illness syndromes may providers in our communi- resources, and clinical issues; and program self-assessment survey for cultural be “culture bound”: the ties. This in turn, will im- competence. It also includes a cultural competency administration self- Western assumption that prove our ability to meet the assessment; cultural competence self-assessment questionnaire, administrative version; administrative performance assessment including financial performance cross cultural variations guiding philosophy of The standards; and a community survey on cultural competence. A copy of Bloch’s in symptoms reflect un- Framework for Support: “to Ethnic/Cultural Assessment Guide is also included. (Excerpted from the web site derlying “core” illnesses help people with mental ill- of the National Technical Assistance Centre for State Mental Health Systems may not always be war- ness live rich and fulfilling (U.S.); URL is http:// www.nasmhpd.org/ntac/cultural.htm) ranted (see, for example, lives in the community.” ORDER FROM: Western Interstate Commission on Higher Education, P.O. Box pages 5-8 in this issue). ______9752, Boulder, CO 80301-9752, Phone: (303) 541-0200, Fax: (303) 541-0291. References Finally, some of the funda- „ From the Australian Mental Health Network Publications Catalogue (at special Beiser, M. “Schizophrenia: Illness price, using order form available from CMHA BC): mental evidence about ill- & Treatment: Cross-cultural ness epidemiology (a field Comparisons. Culture, Communi- ° Evaluating Mental Health Services for Non-English Speaking Background related to determining the ty & Health.” (web site address: www.utpsychiatry.com/noframes/ Communities health of a given popula- cchs.html). ° Assessing Needs for Mental Health in Culturally and Linguistically Diverse tion), effectiveness of treat- Communities: A Qualitative Approach ments, and outcomes related Trainor, J., Pomeroy, E. & Pape, B. ° Culturally Informed Clinical Practice (1999): CD-ROM (1993). A New Framework for Sup- 15 to serious mental illnesses port. Toronto: CMHA. „ Article: such as schizophrenia needs revisiting in light of cultur- Warner R. & de Girolamo, G. (1995). Schizophrenia: Epidemiol- “Rehabilitation & Cultural Diversity,” By Ron Peters, Visions issue on Rehabilitation al factors. For example, a ogy of Mental Disorders & Psycho- & Recovery, CMHA BC. review by Warner & de social Problems. Geneva: WHO.

Visions: BC’s Mental Health Journal Cross Cultural Mental Health No. 9, Winter 2000 cultural competence for providers Doing Cross Cultural Clinical Assessments

Linda Hunt [EDITOR’S NOTE: The work- dicates whether a person’s expectations of the health A process of “principled (St. Mary’s shop described below exam- ethnicity/culture is likely to care provider; and the effect negotiation” was discussed Hospital) ines ways of conducting be an indicator of a chal- of the illness in functioning. as a method of resolving and Betsy Jo- cross cultural assessments lenge in accessing health discrepancies between Spicer, which are sensitive to the care was discussed. This Kleinman’s questions to elicit people providing care and (Vancouver health beliefs of people from refers to acculturation: a patient’s explanatory those receiving health care. Hospital and various ethnocultural back- the process of adaptation health model were offered Fisher and Ury describe this Health grounds. While the focus is through first-hand contact as one of the tools available method of negotiating Sciences generic in nature, its appli- between cultural groups. to health care workers. The differences: Centre) cation to mental health care questions state the intent is apparent.] and the wording. Order or „ First, separate the peo- Four models of timing depends on the ple from the problem. It he objectives of the acculturation: worker’s assessment of the is better to see the prob- Tworkshop were to: integration, assimila- specific situation. The ques- lem as being “out there” tion, separation, and tions are: and have people working Excerpted from „ identify factors affecting marginalization together to attack the Cross Cultural cultural assessments, „ What do you call your problem not each other. Caring, Mount „ identify explanatory problem/what name St. Joseph Hospi- health models, and Berry defines four models of does it have? „ Secondly, focus on tal, Vancouver, „ negotiate the differences. acculturation: integration, „ What do you think has interests, not posi- Spring 1996, assimilation, separation, and caused the problem? tions. People tend to vol. 4, no. 8. Some identified factors that marginalization. Integration „ Why do you think it stake out a position and influence cultural assess- refers to individuals retain- started when it did? defend it as if it were ment are differing health ing their original cultural „ What do you think your personal territory. Often beliefs, family of origin, role identity, as well as becoming illness does to you (and) the underlying interests in the family, rural or ur- an integral part of the dom- will it have a long or are forgotten in the ban background, religious/ inant society. Assimilation short course? battle. spiritual beliefs, sexual ori- occurs when one’s cultural „ What do you fear most entation, education level, identity is abandoned and about your sickness? „ Thirdly, generate a socioeconomic status, and the person merges into the „ What are the chief prob- variety of possibilities level of acculturation. There dominant society. When the lems your sickness has before deciding what to are likely to be more differ- cultural identity is main- caused for you? do. Having too much ences within a culture than tained without any signifi- „ What kind of treatment emotional investment in between people of differing cant relations with people do you think you should one approach inhibits cultures who possess similar from the dominant group, receive? creativity. educational levels and/or separation occurs, or, if im- „ What are the most im- socioeconomic status. posed by the dominant portant results you hope „ Finally, use objective group, segregation results. to receive from the criteria to judge the Marginalization refers to treatment? solution rather than pit- Avoiding stereotypes. people who have lost psy- ting one personal opin- chological and cultural con- ion against the other. Using knowledge about a tact both with their own [EDITOR’S NOTE: Kirmeyer given culture as working culture and that of the dom- suggests another key ques- generalities. inant society; this may be a tion is whether the person In conclusion, the key con- result of either withdrawal sees their health problem as siderations in doing cultur- The importance of avoiding or exclusion. similar to that of another al assessments are process is stereotypes and using infor- person or experience with more important than con- 16 mation about a given culture It was next suggested that whom or with which they tent, there is no magic reci- as working generalities that four dimensions of illness be are familiar. For example, a pe, self-awareness is crucial must be explored with cli- exposed: patient’s ideas similar experience among a for understanding, valuing ents was stressed. about what is wrong; their family member may affect diversity is vital, and inter- feelings, especially fears, their interpretation of what est in and respect for others Berry’s framework that in- about their problem(s); their is going on.] is necessary. Visions: BC’s Mental Health Journal Cross Cultural Mental Health No. 9, Winter 2000 cultural competence for providers Caring and the Culture of Mental Health Professionals

n this discussion, I hope to present briefly the position Minority ethnic group professionals may strive harder to Dr. M. that the environment (the mental health system) belong to the majority group as a validation of their profes- Oluwafemi combined with individual characteristics of prof- sional standing. In the process, they adopt belief systems that Agbayewa essionals can impact the care we provide, especially are consistent with the majority. What accompanies this to minority group patients. adoption of the majority belief system is a rejection of mi- III nority belief systems. To show oneself as being professional, Dr. Agbayewa is The medical/health care environment affects the way we one rejects what is considered non-professional, i.e., minor- a psychiatrist perceive patients and therefore provide care. For instance, it ity belief systems. In fact, the Australian report concluded at the Mood is not unusual for a patient presented to the emergency de- that nursing is a socially and culturally constructed profes- Disorders partment as having a prior psychiatric illness to be referred sion with practices that are shaped by dominant ideologies Clinic at the to the psychiatrist without detailed physical examination. within the country of training and qualification. This is true University of The same is true of psychiatric settings where we focus more of all professions. In the medical profession, it results in British on mental illness to the neglect of physical conditions. Be- increased focus on biomedical models despite the promises Columbia. cause health care professionals are human, and interact with of biopsychosocial medicine. The profession should heed the each other, they are affected by their own environment and warnings of Rothschild (1998) and Ruiz (1995) that if phy- influenced in their practice by this same environment which sicians focus solely on the biomedical approach to treatment includes their colleagues and their colleagues’ belief systems. of disease, they will invariably misunderstand the patient and miss valuable diagnostic cues. Poor outcome and non- Our attitude and approach to mental illness results from our compliance inevitably follow from this. beliefs about the condition. As professionals, we speak our own languages and in codes that may not be easily under- Our individual belief systems as human beings and as pro- stood by others. We belong to a group. When we speak in fessionals influence the way we apply the scientific data that this way, our care may be misinterpreted as non-caring. It is we acquire. A recent discussion of the intersection between often difficult for our patients to break this language barri- various cultures noted the potential for conflict between the er. Our language, which is evidence of our belonging and collectivist cultures of Asia and Africa with the individualist our education, may unintentionally put a barrier between culture of North America. This is not limited to the political us and those we are trained to serve. arena or financial arena, but also operates within the health care system. For instance, the role given to family members A thirty-eight year old woman was furious about the way in decision making and participation in the health care de- she was treated by staff at a hospital. She complained that livery system has been limited. (I recognize that the new she was maligned with the diagnosis of borderline person- Mental Health Act seems to have recognized the role of the ality disorder. Once this diagnosis was made, her treatment, family, i.e., the extended family system in the health care the approach to her, and her perception of her illness changed delivery of individuals with mental illness.) Mental health — it became more negative. She felt that staff no longer took professionals often conclude on the “rights or wrongs” of a her distress seriously. The technical language with its own particular set of cultural beliefs or practices that they en- unique, often non-traditional meaning, must be translated. counter in their professional practice. The assumption is that the predominant North American set of beliefs is the right Studies of work environment and related issues in “non- one. While the health care professional’s values may differ English speaking background” nurses in New South Wales, from those of the patients, it is the recognition and implica- Australia concluded that professional relationships and sta- tions of these differences that count. tus are often altered when one goes into a work environ- ment in a different country. This is especially so if one were This discussion hopes to raise our awareness of the fact that to be classed as a minority. Instead of being seen as a profes- in various areas within our practice we will respond to spe- sional competent in one’s work, one is seen first and fore- cific aspects of the way patients present themselves. This starts most as a minority with associated expectations. This modified with the description of the symptoms and carries through role and “deprofessionalization” happens not only with col- to our diagnosis and treatment. Our responses are influenced leagues but also with patients. This often results in a situa- by our belief systems. Though we use the scientific model as tion in which non-majority ethnic group members are a basis for our actions, the actual result is a combination of 17 stripped of whatever powers or privileges are associated with restrictions imposed by other pressures, i.e. the system, and their professional groups. They are treated differently than our individual characteristics. In a past era, when it was not other professionals who belong to the majority ethnic group. considered a scientific crime to quote Freud, this idea would be referred to as “counter-transference.” It exists within all interactions whether at an individual or systemic level. Visions: BC’s Mental Health Journal Cross Cultural Mental Health No. 9, Winter 2000 PROGRAMS AND APPROACHES

Ron Peters he Multicultural ethnic general public TMental Health Li- The with information on se- aison Program was rious mental illness: created in 1990 with What are they? What are grants from all three Multicultural their causes and out- levels of government comes? What treatment and a private founda- options are available? How Ron Peters is tion. The program mod- Mental Health does one access these serv- Director of el was the culmination of ices? We also target staff in Planning & two years of community Liaison Program the mental health system with Evaluation for consultation involving education on topics related to the Greater more than two hundred peo- cross cultural service delivery, as Vancouver ple 1. It has been a permanent well as providing them with infor- Mental Health program of the Greater Vancou- mation on existing settlement and ad- Service. ver Mental Health Service since aptation services for immigrants and 1992-93. refugees. Education is given to ethnic com- munity gatekeepers (e.g., about the components The purpose of the program is to increase the appro- and mandates of the mental health system and how to priate utilization of community mental health services by make well-targeted referrals), and to other human service seriously mentally ill members of ethnocultural minorities providers. The general goal is to provide information that in Vancouver and Richmond. We hope to achieve this by increases the chances that people with serious mental health increasing the accessibility and responsiveness of these concerns will be recognized and referred into the system in services. a timely and effective manner.

To accomplish this purpose we defined a new role in the There are two main targets for consultation and service bro- system — one that acts as a link and a mutual change agent kerage activities: ethnic community gatekeepers and clini- between community mental health services, the ethnic com- cians. Ethnic community gatekeepers can be provided with munities, and the existing network of individuals and agen- mental health consultations to determine whether a refer- cies providing human services to immigrants and refugees. rable problem exists and assistance in connecting clients with ______The program currently has a staff of five, consisting of one appropriate resources. Clinicians can receive cultural case Footnote full time person to work with each of the following commu- consultations and active assistance in connecting clients with nities: Chinese, South Asian, Latin American, Southeast Asian the full range of services needed from settlement and adap- 1 Peters, R. (mainly Vietnamese), and First Nations. tation agencies. “Increasing the responsiveness of mainstream The approach focuses on indirect or facilitative services such We have intentionally de-emphasized direct clinical servic- mental health as education, consultation and training, service brokerage, es in this program. The intent is that the Liaison Workers act services to and service coordination. Some direct clinical services are mainly as systems change agents — the goal is to increase ethnocultural the capability of all staff within the mental health system to minorities.” offered, depending on the skill set of the staff member, and (1993). In R. almost always in the form of co-therapy with existing work effectively with the full range of people in the com- Masi, L. Mensah clinical staff. munity they are mandated to treat. Our concern is not to & K.A. McLeod overload the workers with requests for direct service to the (Eds.) Health and Cultures: The target populations of the program include members of point where they cannot provide the other (primary) serv- Exploring the the general ethnic public, community gatekeepers (e.g., eth- ices of the program. We also do not wish to create parallel Relationships. nic workers in immigrant-serving agencies or in private prac- service systems for ethnic minority groups. Volume II. Oakville, ON: tice), community mental health staff, and other mainstream Mosaic Press. service providers who work in areas such as immigration, This program has been evaluated very positively in meeting 187-203. education, welfare, and the broader health disciplines. its specified goals. To more fully meet the needs of seriously mentally ill individuals from ethnic minorities, the program A basic premise of the program is that improved working should be supplemented by other activities. The Greater Van- relations betweeen community mental health, the ethnic gen- couver Mental Health Service has submitted a proposal to eral public, and community gatekeepers will come about as the Regional Health Board to develop English as a Second a result of a process of mutual learning and accommoda- Language programs directed specifically at people with men- tion. This must involve a flow of information, a correction tal illness. We are also helping the Regional Health Board to of misinformation, a modification of attitudes, and a shar- develop an implementation plan for their recently approved 18 ing of expertise that moves in both directions. The purpose employment equity policy. Finally, we believe that encour- of the program is to create positions that could act as “mid- agement should be given to recent pilot projects that have dle men” in facilitating and directing the required flow of created certification programs for health interpreters, that information and expertise. this should be expanded to include additional training for mental health interpreters, and that clinicians also need to In terms of education, our first priority is to provide the be trained to work well with interpreters. Visions: BC’s Mental Health Journal Cross Cultural Mental Health No. 9, Winter 2000 programs and approaches First Nations Liaison Work: A Feature Interview with Perry Omeasoo

hat follows are the highlights Wfrom our feature interview with Perry Omea- spiritual matters. So I kind of couver Foundation, to set up nurses, doctors, hospitals. It’s soo (pronounced O-me-a- followed in those footsteps.” the First Nations Liaison important that health care sue), the First Nations Worker position. All the professionals be educated on Liaison Worker for the “We have such a wide as- Multicultural Liaison work- First Nations culture and Greater Vancouver Mental sortment of people from all ers from the different com- spirituality. In my opinion, Health Service (GVMHS). over the province who come munities are situated within that would make them more (to the Lower Mainland)… different teams within the approachable. It’s amazing Visions: Can you tell our and from all over Canada … city, and I’m at the Strathco- how some of the younger readers a bit about your- In reality, it becomes almost na Team at 253-4401. One professionals [especially] are self and your background? flowing with Natives as peo- of the reasons they put me more prone to be asking ple flood in, and other peo- here was because of the high questions and want to follow PO: “Hi, my name is Perry ple who’ve gotten tired, number of First Nations peo- me around and ask to at- Omeasoo. I’m a Cree Native disillusioned, or bitter about ple that come through the tend workshops and attend from Hobbema, Alberta, a big city life are going back downtown core …” sweats and native ceremo- mental health worker for the to the smaller communities nies, talking circles. It’s GVMHS, and I’ve worked in — from where they came.” “I spend a lot of time down amazing how they’re really the counseling field for the here at the Team, and I’m at open to that.” last nine years. I’ve had ex- “…You know, I can see the a place called Native Coun- tensive experience as an out- single mother on Commer- seling & Courtworkers. I rent “Another part of my job is reach worker. I’ve worked as cial Drive with six kids, liv- a space there because it’s to provide consultation, and an HIV/AIDS worker down ing on social assistance and more accessible for First that would include giving here, as an alcohol and drug trying to access a youth Nations people to come advice to doctors and psych counselor, and I’m also worker for her teenage chil- through the door — they nurses regarding First Na- trained in critical incident dren so they don’t get caught won’t be coming to a white tions people, again around stress management and con- up in alcohol and drugs, and institution and it’ll be a bit spirituality, culture and lan- flict resolution. I sit on a her trying to be a positive more comfortable for them guage. For the other multi- number of boards and com- role model for her children. to see me.” cultural workers, language is mittees in the Lower Main- It’s a difficult, difficult place a big part of their programs, land, and I try to keep to be and lot of people think “There’s four aspects to my for mine it isn’t: all Native pretty busy within the they’re going to find a bet- position. The first one is ed- people know how to speak community.” ter life, and that doesn’t al- ucation: I’ll provide educa- English. …The doctors and ways happen here…” tional workshops around psych nurses will come in, “So I come from a wide va- mental illness for First Na- give the clients their medi- riety of experiences, but Visions: Tell us a bit about tions communities, for First cation, and then they’ll come where my passion for help- your job. Nations professionals, and back in two weeks to get ing the community all stems even for some of the Native their medication again, and from is my strong spiritual PO: ““I work at GVMHS reserves in the area — the there’s no kind of connec- basis, as a pipe carrier. And under the Multicultural Li- Musqueam, the Squamish if tion. Part of my job is bridg- my strong spiritual base aison position and I’ve been they wanted it, to all the Na- ing that gap — that’s where comes from my family, and working here for almost a tive organizations within the consultation comes in.” especially my grandfather, year and a half. Though the Lower Mainland, probably who I guess white people Multicultural Liaison pro- about 60 or 70. It’s a big “…Because I’m a fairly ex- would call a medicine man, gram was started seven or community, probably 60 or perienced outreach worker, but I always looked at him eight years ago, it’s in the 70 thousand in the Lower I don’t have any problem as someone who did ceremo- past year that they finally got Mainland…” going in people’s homes, or 19 nies … and always had peo- money from the Vancouver/ hotels, or Native housing ple coming to the house and Richmond Health Board, and “There’s also the education units to get clients and seeking advice from him on another part from the Van- of non-native people: psych bring them in for their appointments. That’s part of my job. Another part is Visions: BC’s Mental Health Journal Cross Cultural Mental Health No. 9, Winter 2000 programs and approaches

making them feel comforta- that’s where service broker- community … So, I’ll come community, especially in ble, because a lot of times age comes in, because that’s in, and find out if staff have housing complexes, are fear- when a client is suffering what it is, to provide servic- booked appointments for ful about clients with men- from mental illness, he’s a es to a client with a long time me, I’ll attend assessments tal illness coming in.” little uncomfortable to talk abuse history, or finding the with clients, or I’ll go to St. to a psych nurse or a doctor, addict a referral to a thera- Paul’s or other hospitals to “Another [barrier] is com- because we’re asking the cli- pist. Maybe a First Nations try to connect with clients… munication… it really seems ent a lot of personal ques- therapist would be easier This morning I spent an that I have to be vocal and to tions regarding sexual abuse, than a non-Native one.” hour on Main & Hastings be seen for the services to be substance abuse, family vio- trying to track down a client utilized because the First lence. We’re really probing “Another part of my job is who moved from one of his Nations people are prone to at this point: that’s part of to provide co-therapy with hotel rooms last welfare day not use the services if they’re what the assessment is all clinical services. I probably and we don’t know where not right there. And they’re about, but it’s amazing how carry a caseload of four or he’s living, and because he’s not too keen on coming to a Native people feel more five now; I do a lot of crisis/ late for his meds, we’re mak- non-Native agency anyway, comfortable with another emergency kind of stuff. If a ing an effort to find him…” especially with all the histo- First Nations person sitting client has an episode, and as ry ... Any kind of white in- in the room. It takes some of a result is hospitalized, the “Lookout is a big [place to] stitution they’re a little bit the harshness out of it.” caseworkers will call me af- access people because a lot hesitant to come in and seek ter he’s been stabilized and of clients who migrate will services because a few things “Another part of my job is find out what we can do for end up being homeless and are going to happen: they’re actually providing a face to the client, whether it’s hous- penniless and need housing; going to be filed, numbered, mental health; that’s impor- ing, going to Longhouse cer- and Lookout is an emergen- and given a diagnosis … and tant. A lot of people look at emonies, going to Native AA cy shelter like Triage, so I al- there’s a long history of non- me and think ‘mental health, meetings, or maybe connect- ways make an effort to check trust there, so they’re very that’s such a broad defini- ing with the families: I have in there a couple times a hesitant.” tion,’ but, to us at GVMHS, access to every Native re- week to see if there’s any- our mandate is clients with serve in Canada. [For exam- thing I should be knowing “…That’s where First Na- serious mental illness, so I ple,] I phoned up Manitoba about, or if there are any tions workers like myself are really have to make that and contacted a cousin who new clients there. Lookout’s really a valuable resource for clear. We deal with clients then contacted a sister of really good actually because non-Natives…but there’s with PTSD (Post Traumatic the client.” they’re quite open to phon- definitely a big issue of not Stress Disorder) — we’ll do ing Strathcona as soon as a having enough Native men- follow-up or emergency “… I don’t carry a lot of cli- First Nations person comes tal health workers. I’ve been short term care — but we’ll ents anymore, but with that, in where they suspect a here for a year now, and I refer them on to therapists. it’s maintaining a good rela- mental illness.” can see there’s a need for Especially in downtown core tionship with them, educat- somebody in my position, areas such as Strathcona, ing them around spirituality Visions: What are the main there should be somebody in we’ll have clients who’ll and around culture; because barriers to accessible and First Nations housing, there come in with serious mental there’s a lot of native people acceptable treatment for should be a First Nations illness, but they’ll also come who’ve kind of gotten lost in First Nations communi- worker for education — let’s with an assortment of ill- the system over the last ties? say, the CMHA should have nesses, such as substance twenty years, coming from a permanent First Nations use, or HIV, or maybe they’ll foster care, and being raised PO: “I look around the city worker who’d go around have long-term sexual abuse in a white environment and and I see what’s missing and educate about the serv- issues to deal with…so how living in the cities all their …and a lot of that would be ices — there should be a do we deal with that?” lives, they’re really unaware providing advocacy for full-time education worker of what’s out there regard- housing units. The thing at Riverview Hospital and ... “…And I think by providing ing spiritual practices.” about mental illness is that Forensic — there’s probably education for the staff here when you provide housing, 120 Native people out there, the clients are always going Visions: Can you describe the illness goes away. I’m ac- so there’d definitely be a to leave with something, and a typical day at your job? tually doing that at this point need. I think there should be if the staff don’t contact me and it’s working out quite a First Nations worker for personally, there’s enough PO: “When I first started, I’d well. A Native housing unit every Health Board across 20 information that I’ve left have to do workshops — two in town is providing hous- the province. If we lobby for around …that they’ll always or three a week …probably ing for some of my clients if that it would be incredible. be able to find a phone over a hundred in my first I can ensure that my client It would take care of people number for one of the Na- year. Now that I’ve covered is coming with a psych nurse from every area in the prov- tive organizations in the all the teams and the hospi- and a full team. [This is] be- ince… there would be such community. And again, tals I’m educating the Native cause a lot of the Native a wonderful resource.” Visions: BC’s Mental Health Journal Cross Cultural Mental Health No. 9, Winter 2000 programs and approaches

Visions: In your work, how “Not to take anything away in general; they’re looking to homes, they have brown do you separate what part from the psychiatrist. He was make that connection…” skin, and they don’t know of the client’s experience definitely sick, but I per- anything about being a First is spiritual and what is suaded the client how im- Visions: What kinds of re- Nations person, except by clinical? portant it was to take the sources are available in the way people treat them.” medication in order to sta- Vancouver and in the rest PO: “I had this doctor one bilize him and not to starve of the province? Visions: What about serv- time and he asked me to see himself for eight or nine ices in other parts of the one of his clients, and (ac- days at a time, and to have PO: “I have to say not a province? cording to the doctor) he didn’t want to take his medica- tion, t’s amazing how Native people feel more comfortable with another First Nations person sitting in the room . It IItakes some of the harshness out of it. III PO: “There’s and he a mental health was starving him- worker in the Squamish self and he was delusional supervision when he was whole lot, especially in the Band, and I’m pretty and he was hallucinating, being medicated, to go to a Vancouver area, and I think stumped; if there are others and he was a very angry medicine man, and not to that’s where an organization I don’t know about them.” Native man. He didn’t want fast for more than four days. such as Canadian Mental anything to do with the doc- You know fasting is not un- Health could really [provide Visions: What more needs tor’s suggestions. I was a bit common, but white people a] benefit by providing edu- to be done? hesitant because of his de- would call that starving cational posters, pamphlets, scription — anybody would yourself.” and educational material PO: “It would be great if be — but after about 10 or around mental illness and there was extra money for a 15 minutes with this man I Visions: How can Western- making them First Nations- big poster or pamphlet walked away thinking he concept medicine comple- based — having a First Na- campaign to run across the was a wonderful fellow…he ment Native approaches to tions Educator to talk about province. Actually, that told me he was fasting and achieving wellness for peo- issues around mental illness. would be ideal. But a poster that he wanted to have vi- ple with mental illness? You know this isn’t a job for takes twelve hundred dollars sions, and that he saw an one man, there should be a to make. Because Native peo- animal spirit walking with PO: “I think it’s programs whole team of First Nations ple speak English, it would him and watching over him, like this that are in the fore- mental health workers, and be as small as taking the and he saw himself making front today. GVMHS, by hir- its unfortunate we’ll look at posters and pamphlets we a drum… Because I knew ing a First Nations worker, is this program as an experi- have now and putting Native where he came from, from looking at the wellness and mental program [and ques- designs on them so that they the Brandon area, and I not the illness. The First Na- tion]: is there a need for it? I would be approachable and knew a great deal about tion people’s philosophy on think that the research last acceptable. A Native person what kind of spirituality life is to look at the positive year found that out of the could pick one up and say comes out of there (I could aspects of the human being, clients of GVMHS, 375 were ‘hey what’s this thing? It’s see that) all these things that like the medicine wheel, First Nations, but that didn’t got Native designs on it,’ and the psychiatrist thought where we look at what’s pos- include the referrals to oth- they could read about schiz- were delusional, are all itive in all aspects, whether er agencies and didn’t ac- ophrenia or bipolar disorder consistent [with that spirit- that be emotional, physical, count for the people who or whatever. [I’d need to uality] … And the client spiritual, or mental. We look came through the doors, first] adapt them and make didn’t want to take any med- at wellness vs. illness so hav- where we did some crisis the wording a bit simpler, ication because he thought ing [a program like this] is management, and then went because there’s not a lot of 21 that it would destroy the positive for the clients we on their way. Plus, a lot of my clients that would pick connection with the spirit if serve. I think there’s a lot of clients won’t acknowledge up the ones that are there. he took medication, which controversy around my themselves as First Nations, Unfortunately, if you want to isn’t uncommon for First position, but Native people because of internal racism: get something done, it comes Nations people to believe.” have a strong spiritual sense they were raised in foster down to resources. Visions: BC’s Mental Health Journal Cross Cultural Mental Health No. 9, Winter 2000 programs and approaches Working with the South Asian Community: Difficulties in Cross Cultural Assessment Karin Rai n recent years, there has been a greater recognition that egories, such as depression screening tools, were applied cross culture and language influence individual expression of culturally to address mental health concerns in different Imental distress, psychiatric diagnosis and treatment, and cultural settings, an inherent bias was apparent. Simply trans- Karin Rai is a the delivery of mental health care community-wide. Cul- lating screening tools into different languages overlooks the Mental Health tural concepts, values, and beliefs shape the way mental point that Western psychiatric categories are not objective Liaison symptoms are expressed and how individuals and their fam- and free from the influences of a cultural system. Counselor for ilies respond to such distresses. the Surrey Depression assessment tools also disregard the fact that oth- Delta Immi- Cultural norms also dictate which symptoms and behaviours er cultural communities express mental distress differently. grants Services are labeled “normal” or “abnormal,” and influence the ac- Working with the South Asian community, I have often found Society. She ceptability of mental health services. Clearly, effective men- that many South Asians communicate mental illness with can be reached tal health care cannot be separated from the cultural context reference to social circumstances and physical sensations at 597-0205 in which the formation and expressions of psychic distress which are often expressed through a storytelling style. A pre- (ext. 282). occur. determined search for particular patterns of behaviour may miss the meaning of symptoms. It may also miss an emphasis Working as a Mental Health Liaison counselor for the last on feelings and concepts conveyed by metaphors, imagery, three years at the Surrey Delta Immigrant Services Society, and narrative styles of other cultures (Bose, 1997). one of my roles has been to provide cross cultural case con- sultation to mental health staff in the South Fraser Health Research also supports the phenomenon that “patients from Region. As a cross cultural consultant for the South Asian India, Pakistan, and other non-Western countries ‘somatize’ community, many difficulties have been apparent in the their emotional distress, in contrast to patients in the West- assessment process — difficulties which affect people’s abil- ern world who ‘psychologize’ their emotions more often” ity to engage in mental health services. “Immigrants of South (Mumford, 1992). Somatization means to experience and Asian descent” refers to people who identify India, Pakistan, attribute mental distress and symptoms to physical illness. Sri Lanka, Bangladesh, or Nepal as their countries of origin. Anxious and depressed patients are very commonly found People of South Asian descent may also be from Fiji, parts of in hospital medical settings seeking physical treatment for Africa, and some Caribbean islands. their somatic symptoms.

Assessment of the patient’s cognitive functioning is critical Cross cultural assessment difficulties are also evident when in determining the nature of the mental health disorder. there is a lack of understanding that many contemporary Assessment is ultimately an interpretive process, where the non-Western languages generally lack specific words for health professional, influenced by his or her own culture, anxiety and depression. Punjabi, for example, is a rich and determines through interpretation the mental state of the expressive language for communicating emotional states, but patient. When patients of immigrant groups express a dis- no one word means depression; often a whole phrase is need- tinctly different reporting of culturally structured “familiar ed to express depression or anxiety. Unfortunately, most de- terms,” interpretation of the assessment can be misleading. pression screening tools used in the South Fraser Health Region do not include assessment questions which would To give a very simple example, the depression screening tool address clients who somatize their emotional distress. THE H.A.N.D.S asks, “Over the past two weeks, how often have you been feeling blue?” When using this screening tool for multicultural/multilingual consumers, it was noted that literally translating the question into other languages was not sufficient. Many clients did not understand what is be- ing asked of them, even if they could read or write English. Unless a client had the cultural understanding that blue is ______not only a colour, he or she would have misunderstood the References 22 question. Bose, R. (1997). “Psychiatry and the popular conception of possession among the Banglashesies in London.” The International Journal of Social Surrey Delta Immigrants Services Society has had a Multi- Psychiatry: 43(1). cultural/Multilingual Depression Screening Day event for Mumford, D. B. (1992). “Detection of Psychiatric Disorders Among Asian the last four years. Working with multicultural/multilin- Patients Presenting with Somatic Symptoms.” British Journal of Hospital gual clients, it was noted that when Western diagnostic cat- Medicine: 47(3). Visions: BC’s Mental Health Journal Cross Cultural Mental Health No. 9, Winter 2000 programs and approaches

isions talked to Dawit Shawel from Mental Health and VImmigrant Services Society (ISS) about a client — a recent immigrant from the African Community: East Africa — and her expe- rience with the mental health system. What follows A Service Provider’s Account is based on his account:

The woman’s unfortunate arrested. While the Ministry very important.” experience was triggered by of Children and Families ap- something which most of us prehended the young child, Visions: What kind of men- understand and take for the woman was taken to a tal health issues does ISS granted: an outside light local hospital.” see with its clients who are which is activated by a mo- from the various African tion detector. When she “There, she became even communities? came in or out, the light more agitated, to the point of went on; after she’d returned becoming violent, at which DS: “At this time we mostly inside, it went off. Not being point she was involuntarily deal with people who are familiar with such things, hospitalized in the psychiat- depressed, then at times with she became puzzled and ric unit, where she was traumatized people. So what troubled. In her culture, it is heavily medicated. No at- we do is we only see them common to believe in spir- tempt was made to call in initially, then we refer them its; what she came to believe interpretive help, and ISS to the appropriate resourc- about the lights was that they wasn’t called until two days es, in [the latter] case to the when, I can’t tell you. That’s Dawit Shawel is were telling her that there later. By this time, she was Vancouver Association for the kind of question I ask a Community was something wrong with completely uncommunica- Survivors of Torture.” myself, but definitely there Settlement her place, that she was in tive due to being heavily is a need. There are so many Counselor with great danger, and that she medicated. Visions: What kind of men- people [who have issues]. the Immigrant should leave immediately.” tal health needs are faced Most refugees from Africa Services Society Visions: Can you suggest by people from African can be traumatized because of British And so, she came to be spot- how this situation could backgrounds? of previous experiences. Columbia. ted on an East Vancouver have been prevented? They come from war-torn street, running along with DS: “In most cases, people countries in most cases, mil- her young daughter. A DS: “One of the things that from African backgrounds itary dictatorships, there are neighbour, seeing something agencies like ours are doing, are faced with all kinds of refugee experiences … For outside the ordinary, and and especially ISS, which is things due to major culture many, they don’t realize being concerned for the the first contact for most shock as the differences be- what they’re going through, child, phoned the police, government-sponsored ref- tween the two places are and even if they do know, who came and confronted ugees, is that we have orien- very huge. Aside from that, they find it difficult to com- the woman. Because of the tation sessions to the lifestyle the Africans tend to go municate because it’s very language barrier, she be- that awaits them, though we through bigger racial dis- taboo. They don’t want to be came extremely frightened may not go through all the crimination from every seen as someone with a men- and agitated, and was then little things like motion de- direction, not just from one, tal health problem; that can tectors. But they do know so there is a need for more be seen as a big failure on Related Resource they can call us for informa- support.” their part. So as it is, in most tion before anything hap- cases, they don’t even ac- MOSAIC offers bilingual coun- pens. They have standard Visions: Is there a need for knowledge that it exists.” seling (including information, contacts with workers of the more education for people referral, interpretation, and Immigrant Services Society.” of African background Visions: Thank you very translation services) in twelve about mental health and much for talking to us Da- languages including Somali/ “On the other hand, I guess mental illness? wit. This has been very African. The others are Arabic, Punjabi, Hindi, Urdu, Chinese, before any action is taken by valuable. Before we end, Korean, Persian, Polish, Rus- anybody, be it police or hos- DS: “Mental illness and are there any other issues 23 sian, Spanish, and Vietnam- pital, someone has to make mental health issues are a you’d like to talk about, ese. sure that things are commu- taboo in the African commu- relating to the African com- nicated correctly before they nity, so I know it is necessary, munity and mental health? Phone (604) 254-0244 for reach any [further] stage. there is a need, but if you ask more information. cont’d left The call for an interpreter is me how and where and DS: “Yes, the number of column next page Visions: BC’s Mental Health Journal Cross Cultural Mental Health No. 9, Winter 2000 SOCIAL ISSUES Mental Health and Disorder in Recent Immigrants: Notes from a workshop delivered by Dr. Soma Ganesan, May 1998

Dr. Soma f the 215,000 people im- vulnerable). Immigrant pop- prevalence of mental dis- Ganesan migrating annually to ulations have a higher pro- order more difficult in im- Canada, 17% arrive in portion of younger people, migrant populations. For Dr. Ganesan is Vancouver and many set- who are closer to the typical example, many recent refu- the Medical tle here soon after arriv- age of onset of major men- gees initially go through a Director, ing elsewhere in the tal disorder. period of elation upon arriv- Department of country. The patterns of al. This could be confused Psychiatry, UBC/ Omigration are constantly The factors that affect men- with mania. In many coun- VGH and Direc- changing, with a recent tal health status of recent tries, it is normal and adap- tor of the Cross trend towards increased immigrants are similar, but tive to maintain a level of Cultural Psychia- immigration from Southeast not identical, to the risk fac- suspicion that may be con- try Program at Asian countries. There are tors for mental disorder. Age sidered pathological in Can- VGH. 197 different dialects spoken at time of migration is the ada. It takes some time before in Vancouver. top factor, followed by con- people learn to relax their ditions surrounding pre- guard. Some recent local The risk factors affecting migration (stress, family research has shown that “African Community” — (cont’d) the chances that recent im- composition, expectations), Southeast Asians in particu- Africans that I see in danger migrants develop mental and post-migration variables lar are vulnerable to being of being on the street has in- disorder include language (reception, community com- misdiagnosed with schizo- creased. So that number difficulties, unemployment, position, drop in socioeco- phrenia. These are all issues scares me. I wonder where separation from family, lack nomic status). People from that researchers, service that is heading, because of friendly reception from higher socioeconomic brack- planners, and practitioners there is so much unemploy- the host country, isolation of ets are affected to a greater must consider. ment and so much discrimi- people from their cultural extent, at least initially, nation towards this group of background, trauma in the which may be due to a great- people. There’s definitely a homeland (for refugees and er initial drop in status. need for closer attention to non-refugees), and age at this community in the men- time of immigration (adoles- There are issues that make tal health area. cents and seniors are most detecting and measuring

Cross Cultural Psychiatry Program, Riverview Hospital

This is a multidisciplinary cross cultural program intended to deal with communication barriers, medication difficulties, and issues related to the client’s perception of the illness.

The major goals of the program are to provide culturally sensitive treatment, and to equip clients with basic skills to function within the Canadian culture. The program also provides psychologi- cal and occupational therapy, as well as providing educational events for clients and family members.

24 The staff members have provided cross cultural psychiatry in-service sessions on such topics as “Refugee: Who, What, When?”, “Training of Interpreters,” and “Meeting the Challenge of Treating South Asian Clients.”

CONTACT: Dr. Daszkiewicz, 524-7000, or other members of the team, E2 Ward

Visions: BC’s Mental Health Journal Cross Cultural Mental Health No. 9, Winter 2000 social issues When Two Cultures Collide: Let’s face it, a lot of “us” never considered when we decided to emigrate what it would really be like once the dust of moving finally settled

hey” come here and want to change every ing the fact that it has no bearing on a person’s ability to Dr. Kulbir thing. “They” want to enter our legions with carry out his or her duties as a member of the force. Singh, their turbans on while we have to take our MD, FRCP, shoes off to enter their Gurdwaras (Sikh When a minority (Punjabi) group comes in contact with a MRCPsych, Temple). “We” don’t want “them” to wear majority (Canadian) group, the members of the minority U.K. “ 1 HijabT because “we feel” that it is not simply a religious group have to ask themselves two important questions: symbol but primarily one of oppression. Sound familiar? „ is the individual cultural identity of such value that So is what I heard from a respected elder from our com- it should be retained? Dr. Singh is munity at a recent funeral: “They” are teaching “our chil- „ should positive relationships with the dominant cul- a physician dren” that women are equal to men when everyone knows ture be sought? specializing that is untrue. Men are superior, you know. Can there be Potentially, the answers to these two questions will influ- in psychiatry. two kings in a kingdom? A king and a prime minister ence the degree of stress experienced by the group and the He works at perhaps, but never two kings. And “they” are also telling individual. Vancouver “our” children that it is OK to put “our” old people in Hospital and retirement homes. A positive response to both questions would lead to the least Health Sciences degree of stress and the result would be integration. A neg- Centre, GVMHS, Although it may seem like sheer ignorance, what we read ative response to both questions would lead to the greatest and in private and hear is not completely due to ignorance but to the degree of stress and the outcome would be marginalization. practice. dynamics of acculturation. When two distinct cultures A positive response to the question of retaining ethnicity and Article reprinted intersect, conflict occurs, sparks fly and, fortunately, both a negative response to the question of seeking relationships with permission cultures change. The headlines with which we are con- with the dominant culture would lead to an intermediate from the Mehfil fronted every day are groans of the acculturation change. degree of stress and the result would be resistance. A nega- Magazine, Let’s face it, a lot of “us” never considered, when we de- tive response to the first question and a positive response to March 1995. cided to emigrate, what it would really be like once the the second would lead to assimilation and intermediate stress. dust of moving finally settled — especially the psycho- logical adaptation that would be required of us, our chil- To illustrate the four major options, let’s take the hypotheti- ______dren and future generations. cal example of an immigrant family. Balwant, an account- Footnote ant sponsored by his sister, decides, after getting a good job Our understanding of this adaptation is very important at a large firm, to keep his turban but adopt a suit and tie for 1 A Hijab is a as it has a profound impact on ourselves and those closest work, giving up his ethnic clothes. He is enrolled in speech head scarf worn by to us. I will attempt to explain the process of accultura- classes to improve his accent so as to maximize his chances some tion, both for the group and the individual, the majority of success globally. He gets involved in the local political and Muslim and the minority culture. Let’s also look at the dynamics social scene. He attends and helps organize social events at women. and the stress involved. work. His main socialization, however, remains with people from his own cultural background. He has decided to inte- What is acculturation? It is the interaction, conflict, ad- grate. justment, and evolution of two different cultures when they come in contact with each other. The changes occur His wife, Jaswinder, sticks to her ethnic clothes, speaks Pun- at both the group and individual levels. At a group level, jabi, and socializes exclusively with others of Indian origin. the changes are economic, residential, political and so- She rejects the idea of having anything to do with the dom- cial. For the individual, the changes may be in thinking, inant culture, taking the resistance or separation pathway. behaviour, type of attire, mannerisms, and language. The couple’s son Preet, now called Pete, has cut his hair with When a non-dominant minority culture interacts with a his parent’s permission, is sick and tired of everything East dominant majority culture, one might assume that it is Indian, including the language, culture, clothing, movies, and 25 invariably the minority that must change, for example, especially the food. Pete is determined to completely immerse people having to choose between wearing turbans and himself in Canadian culture, earring and all. He excels in securing employment. This isn’t necessarily so. Both cul- academia and sports, and enjoys snow boarding and rap- tures adapt, such as in the case of the RCMP adopting the ping with his gora (white) buddies. He has opted for assim- turban as an acceptable form of headdress, acknowledg- ilation. Assimilation has its advantages: Preet is considered Visions: BC’s Mental Health Journal Cross Cultural Mental Health No. 9, Winter 2000 social issues

cool by his peers, but his relatives, especially his mother and himself up for a narcissistic injury. Sooner or later, some sister, find his transformation somewhat nauseating. ignorant person is going to prick his assimilative bubble by asking him, “Where are you really from?” Consequently, one Binder, Pete’s sister, still speaks with a faint Punjabi accent, could argue that the assimilative position is, by definition, and has refused to join her father’s speech classes. She is still potentially painful, particularly in the psychological sphere. seething at her parents’ decision to move to an alien culture. She misses her friends back home. Smelling of pungent cur- The most painful existence is that of Binder. Marginality rep- ry powder occasionally, she is rejected by her peers. She, in resents a hopeless and negative view of life. People who adopt turn, doesn’t accept them. Feeling trapped and in perpetual it are most likely working at the periphery of society, vul- conflict, she is marginalized. nerable to the ills of stress and dysfunction. Fortunately, there are only a few such people. Balwant said yes to both questions, choosing integration. The stress of doing so is the least. In this scenario, stress increas- Everyone has to bear his or her own cross of acculturation. es if the majority pursue a political policy of blocking such Based on all that I have read, taught, come into contact with integration because of a wish to deny the importance of a during clinical practice, and personally experienced while minority group’s identity by, for example, attaching social living in England, the USA, and Canada, I have come to the stigma to the turban or hijab. In the case of Jaswinder, the conclusion that the optimal option is that of integration. It is stress is rather high. Having said yes to keeping her identity, superior to assimilation, since assimilation is an option for a she gains the respect of her peers and this increases her visible minority only if members of the majority dominant self-esteem. But having chosen a path of resistance, by say- culture volunteer to go colour blind. ing no to the second question, she is in conflict with the majority group. Opposition to seeking a positive relation- ship with the dominant group can be expected to take its toll in the political and economic arena. ______Reference The position of assimilation, which Pete has taken by reject- Berry, J.W, & Kim, U. (1986). “Acculturation and Mental Health.” In P. Dasen, ing his ethnic heritage, is a fragile one. No matter how whole- J.W. Berry & N. Sartorius (Eds.), Applications of Cross Cultural Psychology heartedly he has been accepted by his peer group, he is setting to Healthy Development. Sage Publications. Structural Barriers to Recovery in First Nations Communities

Glen he rehabilitation and market is diverse and reflects the north have been organ- ments has produced further Schmidt recovery process is a multiple opportunities for ized in a manner that can be difficulty where First Na- Tdifficult journey. In re- work. Finally there is a be- described as “vertical,” tions people have been de- cent years, many people who lief that various services meaning that programs and nied services normally experienced a serious men- such as psychiatry, hospitals, funding arrangements are available to other Canadian tal illness have gained a social work, and nursing are controlled from a central citizens. This situation is sense of hope through psy- readily available within the point: a provincial capital compounded by what might chosocial rehabilitation pro- community or at least avail- like Victoria in the case of be called the two-tiered sys- grams and approaches that able within close proximity. provincially funded servic- tem of mental health serv- are increasingly respectful es, and Ottawa in the case of ices that exist between of consumers’ needs and These beliefs about rehabil- federally funded services. urban-dwelling Canadians wishes. These programs em- itation and recovery do not Vertical control creates and those who reside in re- phasize choice and citizen- fit well for people in north- problems for northern peo- mote northern communities. ship. However, the majority ern and remote locations. ple and First Nations people Access to community men- of rehabilitation and recov- The difficulties are especially in that their needs are mar- tal health is difficult and ery programs originated in acute for First Nations com- ginalized and programs are services taken for granted in urban centres. This fact leads munities which face addi- often designed with a south- an urban centre are non- 26 to some particular beliefs. tional structural problems ern, urban population in existent in most First Nations These include a belief that related to poverty, lack of mind. communities. Psychiatrists communities have a range of economic opportunity, and rarely travel outside of ur- housing options available for systemic racism. The history of jurisdictional ban centres and nurses and consumers. There is also a disputes between the feder- social workers who special- belief that the employment Health and social services in al and provincial govern- ize in mental health and Visions: BC’s Mental Health Journal Cross Cultural Mental Health No. 9, Winter 2000 social issues recovery programs also tend years before they are at the expenditure on the part of ing units need to be more to be urban-based. The re- top of the eligibility list for the province. The federal fully considered in housing Glen Schmidt sult is that people with a housing. The consequences government, the provincial construction plans. The used to be a serious mental illness are of this are that people fre- government, and emerging needs of mental health con- mental health poorly supported in their quently live in multiple fam- First Nations governments sumers must be a part of any worker in communities and they may ily arrangements that are must also work to identify new housing initiative. northern experience frequent and overcrowded and quite and eliminate jurisdictional Manitoba. He disruptive acute care admis- stressful. The person strug- barriers that affect service. Finally, unemployment rates currently sions to distant urban hos- gling to manage a mental ill- are high in First Nations provides pitals. ness may find this type of Second, the lack of housing communities and this can consultative environment to be extreme- and the access to housing only be addressed through services to a A further consideration is ly difficult. within First Nations commu- bold economic and political number of that the cyclical nature of nities are a national disgrace. decisions. Treaty settlements northern BC resource-based economies There are a number of As the federal government and land claims are a vital First Nations places northern people at things that need to happen contemplates its large budg- consideration in this regard. groups and periodic risk for unemploy- to address these structural et surplus, it is clear that Land claims settlements will communities. ment. During the past two barriers. First, provincial money from this surplus not provide an immediate, He is a board years, a downturn in the for- governments must do a needs to be directed toward magic solution, but fair set- member of est industry in northern better job of addressing a major housing initiative tlements will create access to CMHA Prince British Columbia has result- service disparities experi- within First Nations commu- an economic base that, in the George branch ed in high rates of unem- enced by northerners. Short- nities. The nature and form longer term, can improve and an Assistant ployment. Even a relatively ages of physicians and of housing construction also employment prospects for Professor of diversified economy like that nurses as well as costs asso- has to change to represent all First Nations people, Social Work at of Prince George has seen ciated with specialist refer- diverse community needs. including those who strug- the University of unemployment rates hit rals are all considerations Multiple dwelling units as gle with serious mental Northern British 18%. However, the problem that require a committed well as larger single dwell- illness. Columbia. is most severe in First Na- tions communities where unemployment and poverty are at unacceptably high lev- els. Differences in unem- The Mental Health System ployment rates between the general population and the First Nations population are ... as Racist? significant, especially among younger groups who are would like to explore the possibility that the publicly-funded Helen most vulnerable to mental mental health system is racist — and if it is — what can be Turbett illnesses like schizophrenia. done about it. Census data from 1996 showed unemployment rates IThe present system has a standard reason for peoples’ emo- Helen is the among 15 to 24 year olds at tional distress: the medical model. This model says that peo- coordinator

10% for the overall Canadi- ple have a chemical imbalance that can be treated, though of the an population. Among First not cured, by medications. So people end up on pills, liquids, “consumer”- Nations people age 15 to 24, ” and needles for years. A one-size-fits-all system that presents run Vancouver- the unemployment rate itself as totally neutral, objective, and scientific seems re- Richmond stood at 32%. Such unac- moved from or elevated above ordinary people and their lives. Mental Health ceptably high rates of unem- Users of our one- Users of the system are obliged to fit the box they make for Network. ployment make it difficult to size-fits-all, medical- them and some of us would gratefully chop off body parts in incorporate employment as order to make our square peg fit the round hole. one of the cornerstones in model system are recovery. obliged to fit the box So, in effect there is no room for discussion or options. Other they make for them, people (who are wealthy enough to afford private counsel- First Nations people also en- and some of us lors, etc.) have their emotional pain recognized as coming counter major challenges would gratefully from post-traumatic stress issues, abuse, issues of violence, when it comes to housing. etc. People who use hospital psychiatrists are told they suffer 27 The range and variety of chop off body parts from chemical imbalances. housing stock is extremely in order to make our limited and various restric- square peg fit the Sexism, classism, and racism and their effects on peoples’ tions on building mean that lives are rarely seen as possible reasons for torment. Such round hole. cont’d left people can wait up to ten “isms” exist, even if we don’t like to talk about them. column next page Visions: BC’s Mental Health Journal ” Cross Cultural Mental Health No. 9, Winter 2000 social issues Understanding White Power and Privilege Gisèle ver four years ago, I that racism was something In the last four years, I found value white, anglo culture, Harrison, began one of the that people of colour had to that I learned the most about history, achievements, and MSW Omost difficult and live and deal with, but not anti-racism when I partici- experiences as the norm challenging journeys of my as an issue that generally in- pated in workshops and read (Dominelli, 1993). Gisèle Harrison life. The journey was one volved or implicated me. books and articles that ex- is the Education that would force me to un- I saw myself as non-racial plored how racial oppres- In a study by T. John Samuel Coordinator derstand, and then process, or racially neutral, and sion puts people of colour at entitled “Visible Minorities and a Rehab how racism has shaped and considered myself to be a disadvantage and how race in Canada: A Projection,” it Counselor for privileged my life. Until my “colour blind,” thus exclud- privilege puts white people indicates that by the year the CMHA journey began, I was under ing me from any need to at an advantage. Through 2001, approximately 50% of Vancouver/ the false impression, like explore my participation this type of progressive the population of Toronto, Burnaby many other white people, in perpetuating racism. training, I was able to under- and 40% of the population Branch. stand how the illusion of of Vancouver are expected to “whiteness” as neutral, of- be visible minorities (CCIC, “The Mental Health System as Racist” — (cont’d) ten makes it difficult for me, 1997). In other words, by Racism, individual or systemic, has a huge impact on peo- as a white woman, to see the year 2001 between 20 ples’ lives. Change is never easy for people and Vancouver is racism and/or to recognize to 50% of all mental health a rapidly changing city. It is one of the top three most cul- when my own unconscious consumers could be people turally diverse cities in the world. behaviour might uninten- of colour. As such, mental tionally be racist (Kivel, health workers would be The response of the mental health system is to hire “multi- 1996). called upon to serve an in- cultural” or “ethnic” workers to translate pamphlets and creasingly multiracial and hold workshops on “multiculturalism.” In my opinion, most, Most importantly, I learned multicultural clientele if not all of this activity is aimed at helping people accept that if my whiteness is the (Pigler Christensen, 1996). the medical model. place from which I see the world, that I needed to be If our goal is to create inclu- We don’t have workshops on what Aboriginal peoples be- conscious of the enormous sive mental health programs, lieve to be the source of peoples’ distress or ways for the power differential between which transcend racism, and non-Aboriginal population to benefit from their wisdom — myself, as a white mental facilitate equal, collective which is much older than the mainstream system. Chinese health worker, and a client partnerships with people of and other Asians also bring a different perspective, which of colour. As such, without all races, then white mental like the Native one recognizes the mind-body connection. a sound analysis of the ex- health workers should be People from India have Ayurvedic medicine which also has tent of racism, and the pow- encouraged to explore the traditions and learning from thousands of years of practice er and privilege of being “racialness” of their identi- and observation. white, it is very likely that ties. Naming “whiteness” the relationship between a can only serve to displace it Again many people (who can afford it) are beginning to ap- client of colour and a white from its unmarked status preciate other traditions — especially for physical ailments. mental health worker could and locate it in the relations However, the mental health system is still a closed door. unintentionally and uncon- of racism in the field of sciously become an oppres- mental health (Frankenberg, I predict it will be a long struggle to change this system, to sive experience for the client. 1997). Studying white priv- make it more open and more responsive to other models. I found that understanding ilege does not mean being Those of us for whom this is an issue will have to demystify/ the power differentials posed responsible for racism; rath- simplify and move this system so that it can look at peoples’ by racism in my work as a er, its purpose is to raise the lives and offer services that are culturally appropriate and mental health professional individual consciousness of not just window-dressing to maintain the status quo. was further challenged in white mental health work- that all of my training and ers by realizing the crucial At first I was hesitant to write this article. As a white woman supervision has been with differences that being white 28 I thought it would be presumptuous of me. Now I’m glad I white people. Similarly the has had on the way we live was asked. It is offensive to me, as an individual who has theories and approaches I and on the way we work experienced the public mental health system, and as a peer was taught and currently (Kivel, 1996). worker, that a system that is supported by tax payers (and practice were based on we are all tax payers) both ignores and contributes to the traditional white “Euro- cont’d left effects of racism. centric,” male models, which column next page Visions: BC’s Mental Health Journal Cross Cultural Mental Health No. 9, Winter 2000 ETHNOCULTURAL CONSUMERS AND FAMILIES The South Asian Women’s Support Group he South Asian Women’s together to places such as the Vinay Support Club runs every Gudhwara (Sikh Temple) and Mushiana T Friday at the South Van- other places of interest. couver Neighbourhood House. The group is currently facilitat- The support group has been a ed by a former member, and much needed respite from the Vinay is the now volunteer, and is attended isolation that many of the wom- Coordinator by up to nine women. The main en face in their everyday lives. of CMHA BC 12345678901234567890123456

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12345678901234567890123456 12345678901234567890123456 Manjeet’s Story Vancouver Mental Health Serv- 12345678901234567890123456 ice (GVMHS). After her husband died in India seven years ago, Manjeet Many of the women have limited or no English skills. This became very ill, as she was unable to cope with the grief she language barrier prevents them from accessing other con- felt at his death. She recalls she began acting hysterically sumer services and supports which could leave them totally like a “pagal” (mad person) after his funeral, which began isolated and solely dependent on their families for emotion- to scare her family. She was then taken to see a doctor who al support. The South Asian Women’s Support Club provides eventually prescribed her medication for depression. a safe space for women which is culturally comfortable and has no language barriers as all of the women speak Punjabi Shortly afterwards, Manjeet’s eldest daughter, who was then or Hindi. For many of the women, it is a place where they living in Vancouver, sponsored her two younger sisters and can talk about their mental illness openly with other con- her mother to join her. Within two weeks of arriving in Van- sumers. As in most cultures, the stigma surrounding mental couver Manjeet became very ill again, acting “worse” than illness is great and consumers and their family members of- she had done before, and she remembers that she was not ten try to keep it hidden from the rest of the community. able to stop crying. She was admitted into hospital where she stayed for a month. The support group receives no direct funding but is sup- ported by the South Vancouver Neighbourhood House which She remembers the hospital stay as a strange experience — provides its operating costs. One of the Intensive Communi- none of the staff could speak Punjabi and she couldn’t speak ty Support Workers with the Broadway South Team of the any English — but because there were some other Punjabi- GVMHS attends the group every two weeks. Her role is to speaking patients there, she didn’t get too lonely. Over time, provide support to the group whenever needed and to pro- she came into contact with the Broadway South Team of the vide a link between the team and the group. As her team GVMHS and was referred by them to the South Asian Wom- makes most of the referrals to the group, it is a natural link. en’s Support Club.

The activities of the group vary depending on the interests Manjeet finds her medication helps her but she still finds no of the women but the emphasis is on keeping busy and ac- joy in life. Sometimes the sadness she feels in her heart over- tive. In the past, there have been cooking classes, arts and comes her and she loses all interest in the world around her. crafts, and recently, knitting lessons. Speakers are sometimes Although her daughters try to be supportive she feels that invited to give talks on issues such as nutrition, medic- they have lost patience with her illness. She feels that they ations, and exercise. The women also enjoy going on outings think she is making it up, that the reason she cannot get out

______29 References Social Work. London: Macmillan Kivel, P. (1996). Uprooting racism: of Social Service Workers.” In C.E. Press Ltd. How white people can work for James (Ed.), Perspectives on Racism CCIC. (1997). Creating a culture of racial justice. Gabriola Island, BC: and the Human Services Sector: A inclusion: Report of the CCIC diver- Frankenberg, R. (1997). The social New Society Publishers. Case for Change. (pp. 140-151). sity reference group. Ottawa. construction of whiteness: White Toronto: Toronto UP. women, race matters. Minneapolis: Pigler Christensen, C. (1996). “The Dominelli, L. (1993). Anti-Racist Minnesota UP. Impact of Racism on the Education Visions: BC’s Mental Health Journal Cross Cultural Mental Health No. 9, Winter 2000 ethnocultural consumers and families

For further of bed some days is because she is being lazy and doesn’t information on want to help around the house. “What use are you to any- this support one if you’re not productive?” she asks. Although she misses New Mental group contact India, she knows there is no point dwelling on it, her family Preet Pandhar, members are all here; there is nothing for her to go back to. South Health Website: Vancouver Manjeet finds the other women in the group to be support- Neighbourhood ive and she has been able to talk about many things with www.mentalhealthconsumer.net House @ them. “I try and come every Friday, it makes me come out of (604) 324-6212 the house, even when it’s really cold like today” she adds. Terry Morris

Terry Morris is a Shakti group long-time consumer advocate pro- offers strength, vincially and in the South Fraser Health enlightenment Region. The South Fraser Mental Health Consumer Advisory Kanwal fter my marriage in group helped me to learn Network and Development Organization Society (CAN- Grewalson 1968, I migrated to about the natural remedies DO), a consumer-run non-profit group, has launched AVancouver from Ja- that might be available for a provincial web site for mental health consumers. The landhar district in the Pun- optimum health. web site was featured as an interactive poster session jab in India. My troubled at our National Conference in August and was enthu- Excerpt from marriage later ended in di- It is financially impossible siastically received by all who viewed it. The site is The Bulletin, vorce. My husband took the for me to access these intended as a method of facilitating consumer network- official publi- liberty of taking my three naturopathic remedies. So I ing in the province and has many interactive features cation of the daughters to India to be would like to express my and areas for viewer input. The site includes an opin- Vancouver- brought up by his parents. concern that consumers ion page, links to clubhouses, and to consumer’s per- Richmond should have choice about sonal pages as well as links to many sites of interest Mental Health For many years I led a very their healing process and the including those on self-help and recovery. There are Network, depressed life, which result- Ministry of Health should lists of advocates throughout the province and there Vol. 4, No. 2, ed in two major nervous recognize the necessity of will soon be e-mail links to MLAs and MPs. Summer breakdowns. I was intro- alternative medicine and 1999. duced to the Shakti Group have all such treatments cov- One feature of the site is the “What’s Happening” page after my second breakdown ered by medical insurance. where upcoming conferences and workshops can be in 1997, and I received a advertised so that consumers can both attend the events great deal of support for my The Network’s Shakti Group and see what other regions are doing and perhaps rep- emotional state. — based in the Lower Main- licate it in their region. land — is open to women of I realized that I wasn’t alone South Asian descent who The site’s developers are looking forward to develop- going through this terrible have experienced the men- ing the aboriginal and multicultural components of time. There are other like me tal health system. Its aim is the site and are in the process of establishing working facing the same life stresses. rehabilitation through mu- groups to plan the content of those pages. It is impor- By interacting with other tual caring and support, cul- tant to the developers that the aboriginal and multi- members, we shared our sto- tural solidarity, and help cultural communities have an opportunity to plan and ries and understood that life with adjustments into Cana- “own” their pages. They have a vision that these com- can be better. dian society. The group ponents may grow to be as large and diverse as the meets the first and third main site itself. I was enlightened through Sunday of every month, discussions, seminars, and from 1:00 - 3:00 pm, and The site still has some areas that are “under construc- 30 health fairs about alternative sometimes on Saturdays for tion” but is well worth a visit. therapies. Unfortunately, the special activities. Phone mainstream health system Helen at (604) 733-5570, Funding for the project has been obtained from local does not provide or inform or Nighat at (604) 682- and regional consumer, family, and community funds us about healing our bodies 3269 (ext. 8144), for more as well as from the Legal Services Society of BC. through natural ways. This information. Visions: BC’s Mental Health Journal Cross Cultural Mental Health No. 9, Winter 2000

ethnocultural consumers and families

“ “ “ Voices of Diversity“ he following voices are self-helpers and family mem- Reprinted bers from Chinese-speaking support groups. These from a past

Tgroups meet regularly through Greater Vancouver “I feel supported and“ understood“ “ in“ the group. The atmos- issue of Mental Health Service’s Broadway South team. Interpreta- phere is very positive and accommodating. Visions. “ “ “ tion kindly offered by team“ worker Raymond Li. I feel more capable in dealing with my pain. I am also able to change some of my perspectives in looking at my son’s ill- “I lived with my wife“ for“ almost“ ten“ years and faced daily ness as well as those of my life. Thanks to the help of the problems with her. Yet I did not know she had ‘schizophre- support group. nia.’ Since she started treatment with the mental team my life is becoming more ‘normal’ and a little bit more My son is still not working although he is mentally stable. It enjoyable. appears to me that he is not motivated to find work. I would like to know more about rehabilitation and I would like I benefit a lot from the monthly support group meeting, to find out how my son can be effectively helped to find because employment.”

„ I realize that I am not the only one with such problems.

„ I meet a lot of friends who are able to share their Mrs. Chan has a son with schizophrenia. She has been a “ “ “ experiences on how to look after their mentally ill member of the support“ group for four years. family members. „ The group invites professionals to speak to us. They provide us with good ideas and instill confidence in us “The support group“ has“ helped“ me“ tremendously. I have as being the most significant persons in helping our loved learned not to worry excessively and I have learned to look ones to recover at home. after myself. „ The group gives me a chance to express my daily frustrations. I enjoy all the speakers. They are informative and sometimes „ I can contribute my own experiences and I can also lis- they are even entertaining. ten to those from other family members and workers at the team. I have made some good friends in the group. We keep in touch outside the group. A nice telephone conversation with I am grateful to the team and the support group for their them is often uplifting in spirit.” advice and information on various aspects of mental health.

I am thankful for enlightening the life of myself and of my Mrs. Low’s son also has schizophrenia. She is one of the

entire family.” original seven members who attended the group since

“ “ “ “ the beginning five years ago. John Wu World Assembly on Mental Health “I have been participating“ “ in “the support“ group for almost three years and I still get a surprised reaction from many The World Federation for Mental Health will be holding its biennial new members, particularly family members, when they find conference in Vancouver, July 22 - July 27, 2001 at the Vancouver Trade out that I am a client of the team. and Convention Centre. Four thousand delegates are expected to arrive in Vancouver representing the following sectors: volunteers, profession- I am comfortable in sharing my view on mental health with als of all disciplines, and users of mental health services. other members. Speaking from my own experience, I urge others to stress recovery, to focus on a day at a time and not The Congress will reflect the mission of the World Federation for Mental to dwell on negative thoughts. It is important for me to make Health, which is: my life meaningful and to remain in treatment. ‡ Improving the quality of mental health services and the life circumstances of I can empathize with the parents in the group. Their vicissi- those who suffer from mental/emotional illness, distress and disability, or who are at risk of such illness or distress tudes in struggling with the ebbs and flows of their sons’ ‡ Promoting and protecting the human rights of persons defined as mentally ill and daughters’ illness serve as a solemn reminder for what I ‡ Preventing mental/emotional illness, distress, disability and less than might put my parents through again should I become ill. I optimal function, both in general populations and in vulnerable groups at risk 31 am committed to being well and staying well.” A call for papers will be out in January. For more details on the upcoming Mary is a client-participant of the support group. She is conference or to receive ongoing information contact Peggy Shepard at also a volunteer responsible for organizing the venue for VenueWest at (604) 681-5226. the monthly meeting. Mary is her pseudonym. Visions: BC’s Mental Health Journal Cross Cultural Mental Health No. 9, Winter 2000 ethnocultural consumers and families Working with Families of a First Nations Ancestry

Heather n the Northwest health Wetsue’etan, Iskut, Haisla, as serious.” In my experi- Baxter region, Statistics Canada Hartley Bay, Hagwilget, ence, most of the families of I(1991) estimates that ap- Kitkatla, Lax-Kw’alaams, First Nations ancestry with Heather Baxter proximately 25% of the pop- Masset, Metlakatla, Morice- whom I work define mental is the Northwest ulation are of First Nations town, Skidegate, Tahltan, illness differently than I do. Regional Coordi- ancestry. The First Nations Carrier, Kitimaat, Kitselas, We have to spend time to en- nator for the BC groups represented in this Kitsumkalum, Atlin, Cassier, sure that we are speaking the Schizophrenia area are Métis, Nisga’a, Dease Lake, and other same language. Society. Tsimpshian, Haida, Gitsan, groups (Health Canada, 1995; Young, 1994). Additionally, culture plays an Resources for Consumers and Families Though there are some important role in defining common cultural beliefs, any illness. When my culture Reading Material: each group has a different defines a hallucination as a culture. Additionally, there disease symptom, another „ From the Australian Transcultural Mental Health Network are noteworthy differences culture may define it as a (order form available from CMHA BC): ° Mental Health Consumer Participation in a Culturally Diverse Society, in political beliefs within sign of a great and powerful December, 1999. (A look at innovative strategies for facilitating the and between bands that can shaman. Furthermore, dif- involvement of consumers, carers, and community members of non- affect smooth delivery of ferent members of a family English speaking background in the development, evaluation, and service. group may have differing management of mental health services.) opinions whether a biologi- Language Specific Support Groups (in Vancouver) for In my experience when cal brain disease such as Consumers and Families: working in First Nations schizophrenia is an illness or communities, there is a need a gift from one’s ancestors. „ Cantonese Mutual Sharing and Psychoeducation Group (for family members to establish a common un- Careful understanding and who have a loved one with schizophrenia) derstanding of the definition respectful listening to the Organizer: Broadway South Mental Health Team, GVMHS Meetings: monthly of mental illness. For exam- family are a necessity. Find- Contact: Sophia Woo (604) 251-2264 ple, at a mental health forum ing commonalities in the put on by one First Nations family’s interpretation to „ Cantonese Mutual Sharing (Satellite Family Support Group) group, the presentations in- build upon assists in de- Organizer: Broadway North and South Teams, GVMHS cluded AIDS awareness, Fe- emphasizing differences. Meetings: monthly Contact: Raymond Li (604) 253-5353 tal Alcohol Syndrome and Some families want to work Fetal Alcohol Effect, Trauma, with a culturally appropri- „ Mandarin Psychoeducation Support Group Alzheimer’s Disease, Lupus, ate framework whereas oth- Meetings: first Wednesday of every month Schizophrenia Awareness, ers do not. For example, one Contact: Sophia Woo (604) 251-2264 Critical Incident Stress, and family group, with whom I

„ Depression Self Help and Support Group for Chinese Speakers Stress Management. Some of work, wanted to use a medi- Organizer: Mood Disorder Association these topics do not coincide cal model approach to facil- Contact: Maria Cheung (604) 738-4025 with the BC Ministry of itate their understanding of Health’s definition of men- the information that the psy- „ Richmond Depression Self Help and Support Group tal health. The 1998 Mental chiatrists and mental health Meetings: second Thursday of every month Health Plan (BC Ministry of system were giving them.

„ Caregiver Support Group for Indo-Canadian Families Health) states “generally ill- They said “Give me informa- Dealing with Mental Illness nesses such as schizophre- tion so I can talk like the doc- (language availability: Punjabi, Hindi, & Urdu) nia, major depression and tors.” They followed it up by Sponsored by: South Team, GVMHS bipolar disorder represent saying that “This is impor- Meetings: every other Wednesday from 7:00 to 8:30 (except during the summer) the most disabling illnesses; tant!”. Thus the family was Contact: Rajpal Singh (604) 324-3811 however, it is acknowledged empowered through their 32 that there are others who do knowledge of medical termi- „ The Vancouver/Richmond Mental Health Network offers the following services: not meet this diagnostic cri- nology and the mental health ° Asian Self Help Group teria, but for whom medical system. In another example, ° Latin American Self Help Group ° Shakti Self Help Group (South Asian women) risk and level of impairment, a family wanted to work For further details contact Helen Turbett (604) 733-5570 regardless of diagnosis, de- within their matrilineal termines their mental illness support system with little Visions: BC’s Mental Health Journal Cross Cultural Mental Health No. 9, Winter 2000 ethnocultural consumers and families outside assistance from mental health professionals. Translated These examples demonstrate the need for flexibility and respect when dealing with Mental Health Materials: people of First Nations ancestry. What’s available in BC? Previous knowledge of inter- and intra-band politics can Canadian Mental Health ° Living Together in „ Articles in Spanish only: also play a role in working Association, BC Division the Community — ° Depression with families of individuals Some commonly ° Bipolar Disorder recovering from a mental ill- „ Getting Help When and asked questions ° Eating Disorders ness. Sometimes, to establish How – Available in about mental illness ° PTSD an effective liaison with fam- Punjabi and Chinese. and people living in ° Your Child’s Self- ily members, it is advisable [Brochure. Translated Community Esteem to establish a working rela- by the Prince George Residences ° Substance Abuse tionship with the Band Branch]. These can be Prevention by Council. This working rela- ordered from the „ Videos: Improving Your tionship is established CMHA BC Division or ° What is Schizo- Family Life through training sessions directly from National phrenia? (In with open discussion of Office. Taiwanese) „ Video: issues. Community develop- ° Relaxation Exercise ° Understanding ment strategies for building „ Chinese brochures (Progressive Mental Illnesses. (In partnerships with a First available from CMHA Relaxation in Spanish) Nation community are Vancouver/Burnaby Cantonese) equally important. In con- Branch. To order, „ Punjabi Translations clusion, working in First phone (604) 872-4902 „ Spanish Brochures. ° Mental Illnesses: A Nations’ villages requires ° Understanding Contact Norma Sanchez Resource Book in time to develop a working Depression @ (604) 872-8441 Punjabi Language. relationship and respect for ° Panic Attacks ° Bilingual (English Joint Project of the partners involved. ° Stress Management and Spanish) Greater Vancouver ° Chinese Canadian ° Depression Mental Health Parents and ° Schizophrenia Services Society, Teenagers: Different ° Children and Canadian Mental Perspectives Mental Health Health Association, ° Anger Management ° Your Feelings After BC Division, and the Baby is Born Riverview Hospital Greater Vancouver ° Living and Working Mental Health Services „ Bilingual Booklet: ______with Schizophrenia References: Neuroleptics (available from „ Chinese Brochures South Team, Medical Services Branch. (1995). A [Contact Sophia Woo @ „ Translation of Clarke report of the health of First Nations GVMHS, and CMHA in British Columbia — March (604) 251-2264] Institute Material on: BC Division) 1995. Vancouver, BC: Pacific Re- ° What is Schizo- ° Schizophrenia gion Medical Services, Medical phrenia? Symptoms and Services Branch, Health Canada. Transcultural Mental ° What is Bipolar Management at Health Network Ministry of Health. (1988). Revital- Disorder? Home izing and rebalancing British Co- ° What is Depres- ° The Medications lumbia’s mental health system: The „ Translated mental 1998 mental health plan (Publica- sion? ° Rehabilitation health brochures in 39 tion No. CH,AM.115) Victoria, BC: ° What are Neurolep- languages which can be Mental Health Services Division, tics/Antipsychotics? „ Material Translated for Ministry of Health. downloaded from the ° What is Mental BC Schizophrenia Web at: The Tsimshian: Images of the past; Health? Society: http:// www.atmhn.unimelb.edu.au/ view for the present. (1984).M. ° What is Anxiety ° Atypical Neurolep- 33 Seguin (Ed.). Vancouver, BC: UBC library_information/brochures/ Disorder? tics Press. brochures.html ° What is Geriatric ° Do’s and Don’ts in Young, T.K. (1994). The health of Mental Health? the Management of Native Americans: Towards a bio- cultural epidemiology. New York: ° Mental Health Delusions Oxford University Press. Services of GVMHS Visions: BC’s Mental Health Journal Cross Cultural Mental Health No. 9, Winter 2000 PROVINCIAL UPDATES AND REFLECTIONS

Catharine Salmon Arm ethnic background. We hope Hume to gain more information In November 1998, CMHA Brief Reports from about people’s experiences BC Division and the Con- of the mental health system sumer Development Project from a cultural perspective in the North and South Around the Province and, based on feedback we Okanagan region completed receive, develop recommen- Catharine a Progress Report on the kinds of mental health serv- For more information, please dations that address the Hume is the Salmon Arm and area men- ices that they were supposed contact Catharine Hume at needs of consumers from Coordinator of tal health system. This was a to provide to on-reserve First CMHA BC Division 1-800- First Nations and ethnocul- Special Projects, pilot project to evaluate Nations people and that time 555-8222. tural communities. CMHA BC mental health systems from was needed to develop effec- Division. a consumer and family per- tive working relationships. We are currently in the spective. In this first pilot, we North Okanagan process of gathering data began to include the per- Unfortunately, we received and will be developing rec- spectives of First Nations very few responses to the CMHA BC Division and ommendations for the North and ethnocultural commu- statement about the degree the Consumer Development Okanangan mental health nities by of cultural/ethnic sensitivi- Project has now expanded system throughout the „ working with the local ty of the mental health sys- the Salmon Arm Progress spring. A final report will be First Nations liaison per- tem and were therefore Report to the North Ok- available in June, 2000. son at the Mental Health unable to make recommen- anagan region. We have at- Centre to contact local dations in this area. tempted to improve our fo- For more information, please Native bands and request cus on increasing the contact Catharine Hume their participation in the We therefore made the fol- participation of First Nations at 1-800-555-8222 or Progress Report lowing recommendations and ethnocultural commu- Shelagh Turner at the Con- „ asking respondents — regarding the provision of nities in this second Progress sumer Development Project: consumers, families, mental health services and Report. In Vernon, we have 1-800-491-9611. service providers, and supports to on-reserve First involved the Immigrant other community agen- Nations people: Services Society since the cies and organizations — „ Clarify the local mental beginning of the process and Multicultural Mental to rate the statement “I health system’s responsi- organized two focus groups Health, Campbell feel people within the bility to on-reserve First for people from immigrant, River mental health system are Nations people. refugee, or visible minority sensitive to peoples’ „ Increase liaison time communities. We also at- The Campbell River and cultural/ethnic back- with on-reserve First tempted to involve the Area Multicultural and Im- ground” on a scale of Nations people. Okanagan band in our migrant Services Association strongly agree to strong- Progress Report, however, (MISA) has, over a six- ly disagree. Since that time the Mental the band representative we month period, conducted a Health Centre has had a spoke to was hesitant to be community development With respect to the first member of the Little involved in yet another process to enhance the pro- strategy, representatives Shuswap First Nation pro- study, feeling that First Na- vision of mental health from two local First Nations vide a cultural awareness tions people had frequently service to ethnocultural bands were interviewed. We workshop for Mental Health identified what they needed communities within Camp- found that on-reserve First Centre staff. At the invitation and had received little or no bell River. This project was Nations people had signifi- of the Little Shuswap Nation meaningful response. In ad- designed and financially cant concerns about the lack Chief and Council Members, dition, we have involved supported by the Mental of clarity about the Minis- three Mental Health Centre counselors at both the First Health Evaluation and Com- try of Health’s responsibili- staff participated with oth- Nations Friendship Centre munity Consultation Unit at ty for mental health services. er community agency staff and the Round Lake Treat- the University of British Co- Both First Nations bands that in exploring ways that the ment Centre through the lumbia (MHECCU). participated in the Progress Mental Health Centre could distribution of question- Report expressed a need for provide services more effec- naires. The community develop- stronger relationships be- tively to First Nations popu- ment process, including a 34 tween the local Mental lations. A follow-up meeting We have also asked a follow- needs assessment of ethno- Health Centre and on-re- was then held to provide an up question to the statement cultural consumers and serve First Nations people. It orientation to Mental Health about the mental health sys- service providers, was con- was strongly felt that the Centre staff on First Nations tem’s cultural/ethnic sensi- ducted to determine Mental Health Centre need- cultural issues. tivity, asking people to „ the barriers to accessing ed to become clear about the identify their cultural/ mental health services Visions: BC’s Mental Health Journal Cross Cultural Mental Health No. 9, Winter 2000 provincial updates and reflections

„ difficulties encountered services for diverse cultures service providers have infor- nity, including mental with existing mental in Campbell River. mation or other resources health, there would have health services [Excerpted from the Report translated into other lan- been greater participation „ possible improvements Highlights, available from guages; those who provide from the various communi- to the system to make it the Mental Health Evalua- services such as counseling ties. more effective for ethno- tion and Community Con- tended to have some re- cultural consumers and sultation Unit (MHECCU), sources, but not many. [Excerpted from the Execu- service providers alike. UBC.] Consumers mentioned the tive Summary of the Final lack of bilingual or multi- Report, available from Most of the information lingual professionals, lack of MHECCU.] gathered came from people Multicultural Mental trained interpreters, and from First Nations, Punjabi, Health Community lack of translated materials Vietnamese, and Filipino Development as the biggest barriers to ac- Aboriginal Mental communities. Information Initiative, Penticton cessing mental health serv- Health Working Group was collected in personal ices in the Penticton area. interviews, telephone con- The goal of this project, The next significant barrier The Aboriginal Mental versations, questionnaires, which was funded by was the stigma associated Health Working Group be- English as a Second Language MHECCU, was to involve the with mental illness. gan meeting in the summer classes, and focus groups. Penticton community in as- of 1999. The group was Approximately fifty service sessing the mental health The results of the surveys started by the Mental Health providers were drawn from needs of local minority cul- were analyzed and present- Evaluation and Community all areas of the community tural groups and then devel- ed in a community forum. Consultation Unit (MHEC- that had a relationship to oping local responses to The results of the forum in- CU) and includes represent- mental health including them. dicate that much more needs atives from a variety of health, social, justice, spir- to take place in the field of Aboriginal organizations in- itual and education sectors. The project began in June mental health services in the cluding United Native Na- These people were asked to 1998 with the formation of Penticton area. Some recom- tions, Native Mental Health join in small focus groups a local working group. The mendations include Association of Canada, for information gathering working group met regular- „ seminars or workshops First Nations Chiefs Health purposes. ly and designed a survey for service providers on Committee, Aboriginal Re- which was distributed to multicultural health (in- sources Project, and the From the community devel- health care professionals cluding holistic health or Vancouver Native Health So- opment process a series of who work with ethnic mi- special topics such as ciety as well as representa- local initiatives emerged that norities. A second survey was post-traumatic stress tives from the Canadian address a wide range of also created and distributed disorder) Mental Health Association, needs including: to consumers of mental „ more access to trained Greater Vancouver Mental „ easy-to-do suggestions health services. interpreters Health Service, the Univer- like upgrading office „ trained cultural advo- sity of British Columbia, the signs to welcome con- The surveys included defini- cates Health Association of BC, sumers in their own tions of mental health and „ translated communica- and the Ministry of Health. language mental illness. The consum- tions regarding health „ coordinating communi- er group tended to focus on services for minority The working group’s two ty resources, interpreta- actual causes of mental ill- groups primary goals are outlined tion and translating ness whereas the profession- „ and representatives of below: services al group tended to identify minority cultural groups „ to define best practices „ cross cultural training symptoms of mental illness. serving as advocates or in mental health from an delivered broadly A larger percentage of the advisors to regional Aboriginal perspective throughout the mental consumers (82%) connected health boards or service „ to define mental health health care community isolation with mental illness, providers. from an Aboriginal per- „ outreach designed to whereas only 49% of profes- spective. take services, workshops, sionals felt that isolation One significant problem en- and programs to the and mental illness were countered during the project The group is also hoping to multicultural communi- associated. was the stigma attached to secure funding to analyze ties. mental illness. Many mem- existing data related to Abo- Many professionals said they bers of the minority ethno- riginal mental health. 35 These initiatives have been have problems communicat- cultural community even formulated into an action ing with their patients/cli- refused to discuss it. If the For more information, please plan that will be the next ents. Family members are project had taken a broader contact Vicki Smye from phase of ensuring the en- used most often as interpret- view of the health care needs MHECCU at pager (604) hancement of mental health ers. None of the medical of the multicultural commu- 801-1526. Visions: BC’s Mental Health Journal Cross Cultural Mental Health No. 9, Winter 2000 provincial updates and reflections CMHA and Multicultural Organizational Change: A Brief History of the National Cross Cultural Mental Health Project

Vinay n 1989, CMHA made a was to ensure that CMHA and four CMHA sites — through diversity train- Mushiana national commitment to incorporated the principles the Prince George branch, ing sessions and work- Iundergo a process of of diversity and multicultur- Thompson Region Office, shops. multicultural organization- alism into all of its opera- Nova Scotia Division, and BC „ develop a long-term al change. This commitment tions and worked toward Division — were selected plan to encourage appli- was made in response to the sustaining multicultural or- from the 47 that expressed cations from people of Vinay Mushiana recommendations put for- ganizational change inde- an interest in participating diverse ethnocultural is the Coordina- ward by the Canadian Task pendently of special project in this process. By the end of backgrounds to our tor of the Cross Force on Mental Health Is- funding. this phase, each site had, board, staff, and volun- Cultural Mental sues Affecting Immigrants among other initiatives, teers. Health Project at and Refugees in its report Phases one and two were „ formed a Cross Cultural the CMHA BC After the Door Has Been completed in 1993, the find- Committee to guide their All sites have now complet- Division. Opened: Mental Health Is- ings and recommendations work. ed phase four and the results sues Affecting Immigrants were summarized in the re- „ developed and adopted a of the process are currently and Refugees in Canada port Multicultural Access Multicultural and Anti- being evaluated and docu- (1988). The report also con- Within a National Organiza- racism Policy. mented. cluded that the mental tion: Report on a CMHA „ drafted an Action Plan health system was largely Initiative. The research con- for Change. inaccessible to, and therefore ducted found that as an or- „ strengthened or initiated Work at CMHA underutilized by, people ganization links with local multi- BC Division from diverse ethnocultural „ CMHA did not reflect the cultural and Aboriginal groups. cultural diversity in the communities and organ- general population in izations. CMHA BC Division has ex- To follow up on the Task Canada on any level. A full report on the results perienced many changes Force’s findings, CMHA’s This included CMHA’s of phase three is available during phase four of this National Board of Directors boards, staff, volunteers, from the BC Division office. project and is still immersed formed a National Work members, or clients. in the process and commit- Group on Cross Cultural „ CMHA was not well in- The final phase of this ted to further change. Mental Health Issues, which formed or responsive to project began in 1998 and Among its many activities was resourced and housed the mental health needs took place over an 18-month and achievements in this by BC Division. In 1992, the of ethnocultural com- period at the four sites. Each phase, BC Division has Work Group obtained fund- munities, which in turn site hired a Coordinator of „ implemented the Action ing from the Department of were unaware of the the Project with the Nation- Plan for Change devel- Canadian Heritage to initi- services available to al Coordinator of the Project oped in phase three. ate an organizational change them through CMHA. being based at Nova Scotia „ strengthened and broad- process consisting of four „ CMHA’s services did not Division. The main objec- ened relationships with core components: take into account various tives of this phase were to multicultural and immi- „ Phase One: Communi- cultural perspectives on „ implement the Action grant serving agencies, ty Consultation mental health and for Plan for Change. both at a local and pro- „ Phase Two: Internal the most part were not „ ensure that policies, pro- vincial level. Assessment available in languages cedures, programs, and „ implemented the Multi- „ Phase Three: Planning other than English or services consider diverse cultural and Anti-racism for Change (policy devel- French. cultural perspectives and Policy throughout the 36 opment and action plan) are responsive to the organization. This rein- „ Phase Four: Change in On receiving further fund- community. forces the Division’s Action (implementation, ing from Canadian Heritage, „ raise awareness among commitment to diversity, monitoring, evaluation) phase three was initiated in staff, board, and volun- inclusion, and elimina- 1995. A National Coordina- teers of issues relating to tion of systemic barriers. The main goal of this project tor of the Project was hired diversity and racism „ developed an Anti-har- Visions: BC’s Mental Health Journal Cross Cultural Mental Health No. 9, Winter 2000 provincial updates and reflections

assment Policy in ac- from over. There will contin- vision also acknowledges cordance with the BC ue to be concerted efforts that despite the project com- R E M O V I N G Human Rights Code. to reach out to ethnocultur- ing to the end of its term, „ organized a number of al communities in an effort there is still much work to B A R R I E R S: training courses for staff, to increase awareness and be done, both at the policy Inclusion, Diversity board, and volunteers on participation in the event. and program level. issues of anti-racism, In addition, discussions have and Social Justice diversity, and multicul- also commenced regard- BC in general, and Vancou- in Health tural organizational ing the development of a ver in particular, has one of Canadian-based, culturally the most culturally dynamic change. “Keeping Canadian Values appropriate, depression populations in North Amer- „ supported branches in in Health Care” Symposium screening tool for use in the ica. Over the coming years this process through Vancouver, British Columbia training, distribution of future. the kaleidoscopic changes in research materials, and the cultural makeup of the May 25-27, 2000 regular updates on the BC Division has also con- community will generate Project’s achievements. ducted research on the avail- increasing challenges for or- Removing Barriers is an initiative on health „ as host of the CMHA ability of translated mental ganizations and agencies issues of vulnerable and marginalized 1999 National Confer- health resources across BC. throughout the province. communities. The objectives are advocacy, understanding, collaboration, and coop- ence, BC Division en- Key areas for development This project has positioned eration on inclusion and diversity within the and gaps have been identi- CMHA to meet these chal- sured that cross cultural Canadian health care system. Community mental health became fied. The Division is current- lenges and provides the ba- groups, social agencies, health institutions one of the main themes ly working with a number sis for ensuring sensitive and and individuals are welcome to participate. of the conference. of mental health and multi- accessible services for all „ succeeded in making cultural organizations to ex- members of the community. Some workshop topics include: cultural diversity and plore the possibility of • Ethnoracial Diversity inclusion a main focus of working in partnership BC Division has derived • Aboriginal Health National Depression to produce translated re- many benefits from its in- • Youth and Children Screening Day. sources for use across the volvement in the National • Poverty province. Cross Cultural Mental • Sexual Orientation • Women’s Health Although there have been Health Project and acknowl- • Health and Spirituality in The Division acknowledges edges the Department of significant achievements in a Multifaith Society this phase of the project, that multicultural organiza- Canadian Heritage for its • Organizational Change much work and many chal- tional change is an ongoing support and encouragement lenges remain. For instance, process that requires com- throughout this process. Deadline for Papers — Feb. 29, 2000 the work on National De- mitment and sustained effort pression Screening Day is far in order to succeed. The Di- There is also room for a limited number of tabletop, booth, or poster displays.

For further information, please see the Committed to BC’s Health Removing Barriers web site at http://www.obstacles.org National Depression Screening Day or one in ten British Columbians, depression is a very real part of everyday life. Unfortu- Marie- nately, very few people (less than one-third) will seek help, despite the 80% recovery rate. Claude The Canadian Mental Health Association (CMHA) saw the need to raise awareness of de- Lacombe pression and, in 1995, joined dozens of other organizations in North America and became involved with National Depression Screening Day. Marie-Claude F is an under- National Depression Screening Day (NDSD) is held every year in October. The event is part graduate of an education and research program called the National Mental Illness Screening Project communica- based in Massachussetts. In BC, NDSD was first implemented as a province-wide project in tions student 1995. At the sites, participants are invited to write a screening test for depression and to at SFU and the speak to a mental health professional about their test results. The mental health professional National suggests potential paths of recovery. No diagnosis is given as this event is educational. Na- Depression 37 tional Depression Screening Day sites also provide free information. Screening Day Coordina- The main goal of the event is to give participants the tools they need to access help. Another tor at CMHA objective is to portray depression as a physical illness no different than diabetes or arthritis, BC Division. thus reducing the shame or fear associated with mental illnesses. These goals are important

Visions: BC’s Mental Health Journal Cross Cultural Mental Health No. 9, Winter 2000 provincial updates and reflections

for everyone, regardless of a person’s cultural background. Abbotsford reaches out to the From the beginning, people involved in the event saw the South Asian community need to pay special attention to BC’s ethnocultural commu- nities. Presently, seven sites in BC are either multicultural or Farther up the Fraser Valley, Abbotsford’s Old Sikh Temple cater to one particular ethnocultural community. was the host of a new site in 1999. Just like the Vancouver Chinese site, this site catered to one ethnocultural commu- Multicultural sites are sites that cater to more than one nity only. Fifty-five South Asians attended the site and were ethnocultural group. For example, the Surrey site provided able to write the screening test and receive information on services in seven languages. One of the first sites to offer depression in Punjabi, as well as meet with a Punjabi- services in a language other than English was organized by speaking psychiatrist. the Vancouver/Burnaby branch of the Canadian Mental Health Association. Stella Lee, Outreach Worker for the Chi- Satwinder Bains, manager for Culture and Health 2000 and nese Education Program at the branch, and her volunteer site coordinator for National Depression Screening Day, saw teams opened their first site in 1995. That year, the site wel- that the screening was a great opportunity to work on the comed 150 Chinese participants. Over the years, the Van- elimination of stigma associated with mental illnesses with- couver Chinese site has attracted almost 1,100 people. in the South Asian community. Satwinder is happy with the positive response received from Abbotsford’s South Asians. For the Chinese Education Program, Stella has two volunteer “Considering it was the first time we held the site, it was teams: the Mental Health Promotion Group which assesses very gratifying to see the numbers,” she says. She adds that needs and develops strategies, and the Chinese Community the community was very open to having the site. “Many were Mental Health Liaison Volunteer Group, which is in charge interested in learning more.” of carrying out activities such as National Depression Screen- ing Day. Stella knows just how important it is to have the The event was publicized through posters and word of mouth. community involved: “You tell them why you are organizing Satwinder also spoke about National Depression Screening the event and they will help you,” she explains. She also point- Day at the Sikh Temple. In some communities, word of mouth ed out that volunteers should come from every section of proves to be a very effective communication tool. A survey done of participants at the 1999 Chinese sites in Richmond National Depression Screening Day 1999 Highlights and Vancouver showed that at least 18% of the participants came after a friend or family member suggested they attend.

„ This year, 1,800 people attended. Satwinder is already looking forward to National Depression „ There were 28 sites in BC. Screening Day 2000. However, for her second year she will „ Seven sites offered services in languages other than English. prepare two different rooms for men and women. She noted „ The most attended site was the Chinese site in Vancouver with 200 that some women were uncomfortable approaching the psy- participants. chiatrist when men were present. „ Almost 500 participants (25%) used services in a language other than English. National Depression Screening Day 2000 is just around the „ Resources were available in nine different languages. The site in Surrey corner. As the planning process begins, some goals are al- provided services in eight languages. ready quite clear. For the third time, we will focus on attract- „ Some sites were specific to one ethnocultural community. The Abbotsford ing participants from ethnocultural communities. Sites will Old Sikh Temple was open to South Asians while Richmond and Vancouver had Chinese sites. be encouraged to keep their multicultural (or ethnocultural) angle, while other sites will be invited to become more cul- „ 15% of the participants who attended the North Vancouver site used services in Farsi or Mandarin. This is an increase of 10% from last year. turally inclusive. CMHA BC Division will also provide the support that sites may need to incorporate multicultural is- sues including, among other things, providing official Na- the community, not just from the mental health field. Her tional Depression Screening Day posters in different volunteers are retired community members, teachers, home- languages. makers, and students, among others. In 1999, BC Division sent a checklist to all site co-ordinators Now in its sixth year, National Depression Screening Day on how to organize a multicultural site. Other documents has become well known in the Chinese community. The were also provided, including one document outlining the Chinese media (television, radio and newspapers) have pro- cultural makeup of each BC community and another which vided extended coverage over the years. Stella knows just detailed an example of a successful outreach campaign for how great the need for help is in the Chinese community another non-profit organization. 38 and has been able to convince the Chinese media and the community of the importance of the event. She explains that It is not by luck that one in four National Depression Screen- some people in the community may have adjustment prob- ing Day participants in BC used resources in a language oth- lems after having immigrated to Canada or feel isolated; oth- er than English; site co-ordinators like Stella and Satwinder ers have family or emotional troubles; still others are feeling have been working hard to make depression and the screen- down after not being able to find a job. ing day a hot topic in their communities. Visions: BC’s Mental Health Journal Cross Cultural Mental Health No. 9, Winter 2000 provincial updates and reflections Diversity, Mental Health, and the Community of Prince George rince George, warmly shop on the cultural per- A memorable highlight for our and remember our Cree Karen Clark known as the “North- spectives of living with staff and consumers was ancestor. It has helped us Verbisky Pern Capital of BC,” is a diabetes. their participation in the explore this part of our an- community which celebrates College of New Caledonia’s cestry as a family. its heritage and cultural Such programs and events Diversity Art Works Mural. diversity. Events such as are constantly improving the “Bird of Prey Perched” Karen is the ethnic family nights or Mul- support network and ulti- The mural, which is dis- Bill Selody Cross Cultural ticultural Canada Day cele- mately the mental health of played in the Atrium of the Though powerful, the eagle Coordinator brations honour and include our diverse communities. College, educates, promotes, is a part of nature working at CMHA our local minority groups. CMHA Prince George has and celebrates the diversity and living in harmony with Prince George. Two immigrant-serving put issues of inclusiveness of our communities. Of the its surroundings. agencies host these events and access in the forefront 500 tiles which beautify the and provide counseling and since 1996 when they were walls, 18 were designed and “Peace and Love” support for new and exist- chosen as a site of CMHA created by CMHA consum- Janice Gould ing immigrants. First Nations National’s Cross Cultural ers and staff. The activity was If we all had love and car- communities have also built Mental Health Project. an exercise in personal re- ing for each other we could strong support systems Through this process, CMHA flection, creativity, and fo- rise above all the discrimi- through such organizations has created culturally sensi- cused on issues of diversity, nation, hatred, and violence as the Native Friendship tive policies, programs, and multiculturalism, and their in the world. Centre, the Native Health services with the ultimate meanings. Short statements Centre, the Métis Elder So- goal to remove all systemic accompany each tile, which ciety, the Native Art Gallery, barriers. Workshops, pro- express the artists’ intent of CMHA is proud to be a part and the Carrier Sekani Tribal grams, and events are ongo- their creation, such as: of such cultural activities Council. ing for staff, volunteers, and and is committed to sustain- board members in order to “Totem Pole in the Street” ing partnerships with di- The issues and needs of our educate them on key issues Debra, Stace, and Shea verse groups and ensuring diverse communities have of cultural diversity and Zsombor that the mental health care long been discussed, yet ac- mental health. By creating this tile we hon- needs of all people are met. tion is now more visible as local support from main- stream businesses, institu- A more comprehensive resource list can be found on CMHA tions, and organizations is BC Division’s web site at http://www.cmha-bc.org. Also beginning to reach our mi- be sure to check out the resource sidebars on pages 10, 15, nority and First Nations 23, and 32. communities. Diversity, or- ganizational change, and the Articles and Reports removal of barriers which impede the participation of A persistent spirit: Towards understanding aboriginal health in Brit- ish Columbia. (1995). In P. Stephenson, S. Elliot, L. Foster & J. Har- diverse communities is be- ris (Eds.), Canadian Western Geographical Series, 31. coming a priority. For exam- ple, the College of New Toward full inclusion — Gaining the diversity advantage: A guide to Caledonia began a Diversity planning and carrying out change in Canadian institutions. (1993). Initiative Project in 1997 Ottawa: Department of Canadian Heritage. which focuses on increasing awareness and understand- Nymen, B. (1992). Increasing access: Developing culturally acces- ing of diversity within the < sible mental health and social services for immigrants and refu- gees. College and the community urce List s Winnipeg: CMHA Manitoba Division. it serves. The University of Northern BC has also re- Canadian Task Force on Mental Health Issues Affecting Immi- 39 ceived funds to initiate a grants and Refugees. (1988). After the door has been opened: Mental health issues affecting immigrants and refugees in Cana- similar project. The Canadi- Re an Diabetes Association has made a commitment of change and hosted a work- over Visions: BC’s Mental Health Journal Cross Cultural Mental Health No. 9, Winter 2000 40 V6E 3V6 Vancouver, BC 1200 -1111 MelvilleSt. BC Division HealthAssociation, Canadian Mental Res < urce List produced a number of resources. Forfurther information andto anumberof produced itskindoperating withinananti-racismframework andhas of first who experience isthe severe Centre mentalhealthproblems. This ethnoracialcommunities topeoplefrom services provides Centre systemic racismwithinthementalhealthsectorinCanada.This relating todiversity andhealthcare. andvideos otherresources Diversity Officealsohasanumberof Vancouver:Joseph Hospital, costis$15.The (604)877-8508.The Diversity The OfficeatMountSt. from videocanbeordered This tion byDr. Tafoya. Terry page (SeeGuestEditorial, 3inthisissue) Bowen Stevens, S. (1993). son (Eds.). BritishColumbiaPress. Vancouver: University of Women’s Issuesfromatraditionalperspective]. bookexamines America.[This Native American University Pressof the Human Services Sector: ACaseForthe HumanServices Change. tal HealthCentre. tal Hear WhatWe AreSaying; AcrossBoundaries:AnEthnoracialMen- Befriending demons:Healingacrosscultures. Videos ern Canada. Cross culturalcaring:Ahandbookfor healthprofessionalsinwest- F.A.Paniaqua, (1998). Books da. resources cultural society. Toronto: University of Toronto Press. Toronto UniversityToronto: of E.J.racism.” (1996).InCarl, (Ed.), poly-versity Organizations touni-versity: From intransitiontoanti- Albers, P. &Mediane, B. (1983). Clients. APracticalGuide. Ottawa. (1990)N.Waxler-Morrison, J. &E.Richard- Anderson Manitoba: PlannedParenthood. Toronto. This isanaward This Toronto. winning videoabout —cont’d Assessing andTreating CulturallyDiverse Community basedprogramsforamulti- Sage Publications. TheHiddenHalf. Perspectives on Racismand (1997). Apresenta- Washington,D.C.: (pp. 196-208). „ „ „ Responsiblefor MulticulturalismandImmigration. Ministry cies ofBC). Agen- ofMulticulturalSocietiesandService AMSSA (Affiliation Organizations Australian TransculturalMentalHealthNetwork http:// www.atmhn.unimelb.edu.au/ Quebec. Montreal, Social&TransculturalPsychiatry,Division of McGillUniversity, http://www.mcgill.ca/Psychiatry/transcultural/prr.html Web Sites order, accesstheirweb siteathttp://www.web.net/~accbound itaee(604)572-4060 596-4357 (604) Vietnamese Multilingual Helpline andVietnamese Urdu, Spanish, jabi, South AsianLine Chimo CrisisLine Victim Information Line: Crisis Lines and anti-racism. Examples of theseare and anti-racism.Examplesof immigrantes many publicationsonmulticulturalism, settlement, thisgovernment organization produc- Communications Branch of and their resources, accesstheirweband theirresources, siteathttp://www.amssa.org site at:http://www.mrmi.gov.bc.ca the CommunicationsBranch (604)660-2204oraccesstheweb ticultural, andImmigrant Organizations).Toorder, Service call Ethnocultural,Mul- of 1999(Directory EMISODirectory The Immigration 1986-1996. of A Profile Guide toMulticulturalPolicy for Institutions(1995) For more information onthisprovincial organization information For more in Cantonese, Hindi, Korean, Mandarin, Pun- Mandarin, Korean, inCantonese, Hindi, adrn(604)279-8882 (604) Mandarin Cantonese B aeCieUi 1-800-563-0808 BCHateCrimeUnit in Chinese, Spanish, Korean, and inChinese, Spanish,Korean, 278-8283 The