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Canadian Psychiatrists Confront Cultural-Competency Challenges

How does one provide culturally competent psychiatry in one of the world's most immigrant-friendly countries? Canadian psychiatrists who have had experience in this domain proffer some answers.

And there they were, the Moroccan daughter and her mother, in a Toronto hospital emergency room. The daughter was suicidal. Could it be because she was possessed by a malevolent spirit—a "djinn"? The mother thought so. Then the daughter admitted that she had done something terribly wrong. "Have you disgraced our family?" the mother asked.

Laurence Kirmayer, M.D.: The more psychiatrists know about the circumstances of where immigrants come from, the better they can help immigrants redefine themselves.

Marie-Eve Cotton, M.D., a Quebec psychiatrist, has worked with the Inuit peoples for six years.

This scene was play-acted by two psychiatrists at the annual meeting of the Canadian Psychiatric Association (CPA) in Montreal in October to provoke a discussion of how psychiatrists should handle such situations.

The scene is also an example of the cross-cultural challenges facing Canadian psychiatrists for several reasons—Canada is composed of peoples from numerous backgrounds, immigrants are settling in more areas of the country, psychiatrists are seeing more patients who have been tortured in their home country, and Canada is one of the world's largest immigrant-receiving countries. Some 150 languages are spoken in Toronto alone.

"I call it hyperdiversity," Laurence Kirmayer, M.D., director of transcultural psychiatry at McGill University, declared at the CPA meeting, whose theme was culture and mental health. "It is extraordinary."

Also extraordinary is the plethora of challenges Canadian psychiatrists face if they want to understand patients from different backgrounds and to help them, several speakers noted.

Certainly language is a daunting problem. Lisa Andermann, M.D., a postdoctoral fellow at the University of Toronto, said she sometimes uses an interpreter, but even so, the interpreter and patient may get so involved talking to each other that they forget the psychiatrist is there. Interpreters cannot always give a psychiatrist the context of what is going on with a patient, Dennis Kussin, M.D., a psychiatrist at Toronto Western Hospital, pointed out.

Patients may not be able to read the labels on medications because the labels are not in their native language, said Jose Silveira, M.D., also of Toronto Western Hospital, whose mental health clinic serves about 280,000 Portuguese-speaking people.

Patients from other cultures may have unconventional ideas about the causes of mental illnesses. One Inuit (Eskimo) patient with schizophrenia told Quebec psychiatrist Marie-Eve Cotton, M.D., that he wondered whether his "voices" meant that he was an Inuit shaman—that is, had the power to heal. Some Christian Inuits believe that mental illness is due to possession by the devil and that exorcism can heal it.

Not a few ethnic patients are troubled by identity, a concept that has to do with where they come from and where they are going, their social position, experiences that have affected their lives, and their perspective on the world. Trying to help ethnic patients redefine themselves is not easy, Kirmayer conceded.

Nor is it easy to help patients from other cultures deal with their social predicaments. Sometimes people of various ethnic backgrounds make an appointment with Andermann not because they are mentally ill, but because they have a social need, such as housing, and hope that she will provide them with a letter of recommendation.

Migration has not been found to be a risk per se for mental illness, but some factors associated with migration, such as a drop in socioeconomic status, are. "It is not unusual in Toronto to find physicians driving cabs," said Kussin. One can't help but wonder how they're faring mentally, he said.

Morton Beiser, M.D., a professor of psychiatry at the University of Toronto, and his colleagues studied Southeast-Asian refugees who were admitted to Vancouver from 1979 to 1981. The researchers found that unemployment in this group could lead to depression, as well as that depression could lead to unemployment.

In contrast, many people in this group were not depressed, purportedly because they concentrated on the present and repressed many aspects of their lives in their home country. Thus, repressing the past may be one way that refugees cope with their precarious situation and are able to find their way in their new country.

One reason to think that this is the case is that when Beiser and his team followed the fate of the Vancouver refugees from 1981 to 1991, they found that the refugees had lower rates of depression and anxiety than Canadians in general, that the refugees had done "exceptionally well" regarding employment, and that the refugees' stories were "generally happy ones."

Some ways in which Canadian psychiatrists can help people of various cultures achieve "happy endings" were also discussed at the CPA meeting.

One is to conduct a good cross-cultural patient interview. Adam Quastel, M.D., a University of Toronto psychiatrist who works with peoples who were in Canada before the arrival of European settlers, determines what language or languages patients speak and whether an interpreter is needed. He then asks patients what brought them to see him and why (this way he constructs their stories and also demonstrates that he is interested in them) and asks what their current cultural identification is (which helps him decide how he is going to treat them).

Psychiatrists can also assist immigrants in establishing a new identity. The more you know about the circumstances of where they come from, the better you can help them redefine themselves, Kirmayer advised.

One consideration is the cytochrome P450 enzymes, which are crucial for metabolizing psychotropic drugs and can vary dramatically among ethnic groups. There are now labs in both Canada and the United States that test for differences in the genes that make these enzymes, and such tests can reveal whether the patient can metabolize a particular drug, Joseph Sadek, M.D., a Dalhousie University psychiatrist and psychopharmacologist, reported. "This is a new direction in psychopharmacology service," he added. He and his colleagues have also "used the tests successfully" in their clinics, he told Psychiatric News.

A psychiatrist's being open and nonjudgmental about unconventional treatments may benefit patients from certain cultures. If Inuit patients want to talk about shamanism to understand the voices they hear, Cotton is open to it. But if they want to talk with her about serotonin, that is fine, too. "That is their choice, and the healing factor," she said. She also tells them about the medications she can offer them, but adds that if they want to go to a shaman or a priest for help, she will not be angry at them for doing so.

In fact, unconventional treatments may help such patients. Cotton had an Inuit patient who had been sexually abused and who sought exorcism as a means of healing psychologically. After the exorcism she got better and has remained well for three years. "It left me quite speechless," Cotton admitted.

All in all, Canada is a country not just of incredible diversity, but of considerable tolerance. Thus, if any psychiatrists can offer some good suggestions on how to be culturally competent, it is probably Canadian psychiatrists. "We are uniquely positioned to make a contribution globally," Kirmayer contended.

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