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Tobie Measham, Louise Nadeau, Cecile Rousseau, Deoratias Bagilishya, Patrica Foxen, Nicole Heusch, Louise Lacroix, & Sadeq Rahimi

Introduction

The Transcultural Child Psychiatry Clinic at the Montreal Children's Hospital has a particular history that has contributed to its uniqueness. The clinic's present approach has been shaped through the process of its development, from the moment of its conception to its birth, and then through its ongoing redefinition as a result of the multiple encounters between patients and professionals that have occurred. This has resulted in a particular method of service provision for a unique clientele of immigrant and refugee children and adolescents.

Objectives

The goal of this paper is to describe the Transcultural Child Psychiatry Clinic's development, method of functioning, and clientele. A specific objective is to describe aspects of the clinic's method of functioning which are considered by its personnel to be necessary to meet its mandate: that of providing effective psychiatric services for a transcultural child psychiatry population. Specificities of the clinic's clientele in relation to their sociodemographic profile and their cultural and historical experiences will be described. Parallel to this, both clinical and philosophical aspects of the clinic's method of providing services will be detailed. A particular goal of this paper will be to examine the efficacy of the clinic's method of service provision for its clientele.

Method

The clinic's development and refinement of service provision for its clientele will be described. This will be based on an examination of all 239 cases referred to it from its inception in July 1996 until December 2000. Variables describing the clinic's clientele which will be examined include the age and gender of the referred patient and their country of origin, the reasons for referral as described by the referring source, and the referring source. Events experienced by the clinic's clientele considered to be specific to their premigratory and postmigratory histories will be documented. Variables describing the clinic's method of functioning will also be described. These include the nature and methods of treatment following referral. Finally, outcome, as judged by the clinic's therapists, will be examined. A quantitative analysis of the clinic's service provision will be performed. Representative examples will be provided in order to illustrate the clinic's philosophical and clinical approaches.

Results

1. The Installation of the Transcultural Child Psychiatry Clinic at the Montreal Children's Hospital: the Development of a Service and Clientele

Like many Canadian cities, Montreal has a sizeable and growing community of children and adolescents who are migrants. In parallel, the city also has a well-defined and established network of health care and social services, including mental health care services, for its child and adolescent population.

The Montreal Children's Hospital is one of two pediatric tertiary care hospitals in Montreal that provide services to the city and its surrounding regions. An estimated one-third of the patients seen by the hospital speak French at home, one-third speak English, and the remaining third use other languages in their homes. In addition, the more than 2,000 hospital staff members come from over 45 ethnic groups and speak more than 50 languages and dialects.

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The Department of Psychiatry at the Montreal Children's Hospital has a mandate to provide out-patient psychiatric services to English-speaking youth living in particular geographic regions, called "sectors" in the city of Montreal. In addition, the Department also provides emergency, inpatient and outpatient psychiatric services to Montreal Children's Hospital patients. The establishment of a Transcultural Child Psychiatry Clinic in the Department thus invited a creative tension as professionals attempted to define the mandate of this clinic, as well as its method of functioning.

Both administrative and economic barriers and facilitators contributed to practical aspects of the clinic's development. These facilitators and barriers were in turn linked to the capacity of the Montreal Children's Hospital and its Department of Psychiatry as institutions to welcome this new service and its clientele.

Some facilitators, particularly the hospital's culturally diverse staff and clientele and its Multiculturalism Programme, were already present, and these helped in the introduction of psychiatric services for a culturally diverse clientele. The hospital had established a Multiculturalism Programme in 1986. Among other initiatives, this programme had developed services aimed at staff education and development, community liaison, the collection of resource material, and the organization and training of a bank of linguistic and cultural interpreters readily accessible to hospital staff (Clarke H, 1993).

The idea of a Transcultural Child Psychiatry Clinic within the Department of Psychiatry needed time to find a place and to gain support. This support has been provided amply in terms of the allowance of the team to exist within the Hospital and Department. At the same time, the service remains at the margins. In today's climate of budgetary compressions, it has not been possible to obtain funding for a new service, and economic barriers have presented a challenge to the clinic's functioning and development. Part of the clinic's continued existence has been due to the dedication of people who both formally and informally have leant support to the team. The team functions both as a formal institution, and also relies on social economy (fundraising).

2. Origins of the Requests for the Clinic's Services

An analysis of referral sources reveals that the clinic is responding to a diversity of requests from both within and outside the hospital (Table I). These requests originate largely from health, mental health and social service professionals working in the Montreal region, although some requests for services also originate in other areas of the province. These requests for referral represent a challenge to the existing provision of services along linguistic (French or English) and regional (address of patient) boundaries.

Table I: Sources of Referral of Patients to the Transcultural Child Psychiatry Clinic (July 1996 — December 2000)

The clientele were less likely to be self-referred, with only 5.4% self-referring, than to be referred by a helping professional already involved with the family (86.2%). The source of referral for 8.4% of the patients was unknown. Referrals were received from multiple sources. The largest source of referrals to the clinic from the community and the largest source of referrals to the clinic as a whole at 26.8% originated from social workers and psychologists working in schools and in the city's primary health care clinics. Another large source of referrals from the community at 9.6% were from health and social service providers within the community who have developed a particular expertise in providing services for newcomers. Immigration services and immigration lawyers in the community referred to a much lesser extent, at 1.7%.

The largest source of requests from within the hospital came from the hospital's Multicultural Health Clinic, with 21.3% of referrals originating from this clinic. This medical clinic has been established in order to respond to the needs of newly arrived children and adolescents in Montreal, defined by a length of stay in Montreal of less than two years.

Another important source of requests at 15.5% came from hospital mental health professionals, chiefly from child psychiatrists working on medical wards and in the emergency psychiatric service at the Montreal Children's Hospital, and also to a lesser extent from child psychiatrists working at other hospitals. Referrals from pediatricians and family physicians, at 8.7%, were largely derived from the community, with some originating from within the hospital.

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3. From Referral to First Appointment and Beyond

As a response to the clinic's largely non self-referred patient base, a number of changes to the procedure of accessing services to the Transcultural Clinic have occurred. A related philosophical underpinning to this referral negotiation has been recognition of the power imbalance between the referral source and the patient and their family. As such, a request for services was elicited from the families themselves, in addition to their referral source. When patients were referred from hospital wards, efforts were made to meet these patients during their admission in order to negotiate follow-up. When patients were referred from outpatient departments of the hospital or from the wider community, the referral source was asked to request the family to call the team's secretary either themselves or through a hospital interpreter in order to begin the referral. This resulting contact initiated a complex process of negotiation between referral source, the referred patient's family or their elected representative, and the Transcultural Clinic.

An analysis of the rates of retention from the initial referral to the first appointment and beyond provides some information about this referral process. The largest rate of dropout in the clinic's services occurred prior to the patient and their family's first appointment. Of the 239 referrals, 37, or 15%, did not attend a first appointment as a result of not calling for an appointment after a consultation or referral from a referral source was received, or by canceling or not attending the first appointment. Once the family attended the first appointment, 74% remained in treatment until its completion or currently remain in treatment. Of those offered treatment who left treatment prior to its completion, 13% did not follow-up with treatment after it was offered, while 7% dropped out of treatment later in its course. Finally, 6% of patients left treatment involuntarily as a result of a refusal of their requests for asylum in Canada.

In summary, the largest source of dropout occurred at the initiation of the referral. Given that the overwhelming numbers of patients were not self-referred, this dropout likely represents a negotiation between patient and referring source as to the definition of the problem at hand and the appropriateness of the Transcultural Child Psychiatry Clinic as a means of addressing this problem. This dropout continued to a lesser extent after the first appointment, where a further negotiation of fit likely occurred. Following this, retention in treatment was good, although treatment was uniquely and involuntarily interrupted for a minority of the clinic's patients by external sources: the refusal of their request for asylum in Canada.

4. The Clinic's Clientele

Who then, has been referred to the Transcultural Child Psychiatry Clinic? Over the past four years, 239 children and adolescents have been referred to the clinic. These youth have come from over 70 countries. Table II describes these countries by the top five ranks by percentage of referrals to the clinic.

Table II: Top Five Countries of Origin of Referrals to the Transcultural Child Psychiatry Clinic from July 1996 to December 2000

Three points are noteworthy. First, the vast majority of patients who were referred to the service are recent newcomers to Quebec. Second, the vast majority of youth referred came from countries who have recently or are presently experiencing armed conflict. Third, the countries of origin of referred patients were diverse, with some sharing a closer proximity and others a more distant one to the heritages and values of the French and Anglo Saxon cultures in Quebec, upon which its health and social services (including psychiatric services) have been built.

The population of youth seen by the Clinic who are members of Quebec's Cree community differed in some ways to children referred from other countries. In contrast to the other youth seen by the clinic, this community's presence in Canada, like other aboriginal communities, predates the colonization of Canada by European peoples. In common with the other countries of referral, the Cree community shares a position of being a member of a non-dominant culture in Quebec and has experienced and continues to experience cultural upheaval as a result of the power imbalance between the community and Quebec and Canada's dominant cultures.

A number of events occurred frequently in the histories of the clinic's clientele. First, over half of the clinic's population experienced family separation (56.1%) largely as a result of the family's experience of armed conflict and/or as a result of their migration process. Similarly, over half of the clinic, at 52.7%, experienced organized violence. Lastly, 6.7% of the clinic's population experienced a refusal of their request for asylum. These numbers are all likely to be underestimates, as information was generally lacking for the 15% of patients who were referred to the clinic who did not proceed to a first appointment.

Children from all age groups were referred to the clinic. The mean age of referred children was 10 years. In terms of the distribution of referrals by age group, an equal number of children aged 5 to 9 and 10 to 14 were referred, at 32.2% each, while 22.2% of referrals were for adolescents and 13.4% for children aged 4 and under. In terms of the gender of referred patients, just under two-thirds were males.

5. Reasons for Referral

A description of problems for which children were referred to the clinic was wide ranging. While some problems described by referring sources were similar to problems shared by children and youth referred for psychiatric services in general, some appeared specific to the clinic's clientele (Table III).

The three greatest numbers of referrals for boys were for externalizing and internalizing symptoms (29.8%), followed by internalizing symptoms (25.1%) and then externalizing symptoms (15.9%). Internalizing symptoms made up almost half of referrals for girls (48.9%) followed by internalizing and externalizing symptoms at 15.9% and then externalizing symptoms and psychosis, each at 6.8%. The variety of internalizing and externalizing symptoms were diverse. Questions for referral were formulated in terms of concerns about Post Traumatic Stress Disorder, Attention Deficit Hyperactivity Disorder and learning problems, as well as depression, suicidality and poor social adjustment manifested either by withdrawal or aggressive behaviour. A particular specificity of referral requests were concerns related to the evaluation of developmental delays and of medical symptoms, as well as referrals for the evaluation and treatment of psychotic symptoms and other symptoms with the concomitant use of traditional treatment modalities. Lastly, referrals from primary care providers were specific to this clinic's patient population, and concerned the patient or their family's experience of catastrophic events including genocide, whether or not the children were symptomatic.

Table III: Description of Problem Type (%) By Gender

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6. The Therapeutic Encounter: Treatment Modalities and Outcome

While the above table describes the formulation of the patient's difficulties as presented by the referring source, a reformulation and questioning of the referred patient's experience occurs at the time of evaluation (Rousseau 1998; Measham 1998). This reformulation is a result of the therapeutic encounter between the treating team and the family, and is related in part to the specificity of the clinic's philosophical approach and method of functioning.

The Transcultural Child Psychiatry Clinic at the Montreal Children's Hospital has based its practice on a number of principles, including the process of decentering, the recognition of multiplicity, and the acknowledgement of the role of power relationships in the therapeutic encounter (Rousseau, 1998). The clinical result has been a reformulation of the therapeutic setting, both physically and symbolically, in a manner which invites a complementarity of knowledge systems in order to elicit a multiplicity of viewpoints concerning how a problem is perceived, understood, and responded to. Examples of these viewpoints include but are not limited to the individual, collective, professional, religious, traditional and socio-political. This is in keeping with George Devereux's conception of the principles of work with people from other cultures, where different views, in sequence, shed different rays of light and offer ways of treatment that are not mutually exclusive, but instead complementary (Devereux, 1985).

The treating team, which is multicultural and multidisciplinary, generally meets as a group with the patient and his family, as well as with an interpreter, who helps to negotiate the space between family and team, both as cultural broker and translator. From this a number of treatment modalities are proposed.

The result is that treatment modalities were in some ways particular to this treatment setting. The treatments proposed were often multiple, with over a third of clientele being offered two or more treatment modalities. In addition, these modalities differed in some ways from classical psychiatric practice. Aspects of treatment considered more particular to the team were the proposals of treatment in both the symbolic and real space, a reformulation of the representation of the individual and collective space in treatment, and alterations in the process of treatment. While considered particular to the clinic's work, these modifications of treatment are not unique to the clinic, as they are to some extent shared by child psychiatry in general.

First, treatments were proposed in both the symbolic and the real space. This results from the treatment team's questioning of the principle of therapeutic neutrality. As the previous description of the clinic's clientele has demonstrated, the majority of the clinic's patients are in a position of power imbalance as members of non-dominant cultural groups in Quebec. Part of the referred children's path to well being was considered to involve their and their families possibility of securing a space of physical and psychological safety in order for the children to continue with their development. As such, one aspect of the team's treatment was to provide their services as mediators between the family and dominant society institutions. Treatment modalities proposed included the securing of daycare space for refugee applicant children who otherwise did not have access to this service, the provision of letters for asylum seeking hearings which described a child's experience of war trauma, and the negotiation of conceptions of what was in a child's best interests and who was considered the legitimate parental authority for children who were receiving services from host country authorities mandated to protect children considered to be at risk for abuse or neglect.

A second particularity of proposed treatments was a reformulation of psychiatric treatment modalities in terms of the representation of the individual and collective in the therapeutic process. Thus, dyadic psychotherapy was sometimes reconfigured as triadic therapy, where an interpreter or another team member was present and represented part of the negotiation of the therapeutic space between the values and traditions of the host country and the country of origin. In addition, recourse was made to collective in additional to individual means of understanding and addressing a particular person's difficulties.

Thirdly, the process of treatment was sometimes also altered. In particular, the therapeutic efficacy of the disclosure of horrific events was questioned. A balance between disclosure and nondisclosure as well as a recognition of the particular and sometimes differing needs for disclosure of different family members resulted in a redefinition of the therapeutic space. This led, for example, to multiple concurrent individual and subgroups of therapies for different family members (such as siblings or parents) as the team attempted to provide a containing and securing environment for the family as they negotiated their difficulties. It also led to incorporation of therapies that differ in their emphasis on verbal activity, such as art therapy (Lacroix, 1998, Heusch, 1998). Finally, the role of traditional therapies was also invited into the therapeutic space.

Outcome at last patient contact as judged by therapists was rated as good, moderate, poor or unknown for patients who were seen at least once by the team, whether or not they had completed treatment. In general, outcome was rated as either good (40%) or moderate (24%). For 30% of the patients, outcome was judged as unknown and consisted largely of patients seen once in consultation or who did not follow-up, so that information to determine outcome was not available. Finally, outcome was judged as poor for 10% of the patients. In general, cases with poor outcome shared in common a burden of catastrophic stressors, with the additional component of a worsening of symptoms in the context of severe difficulties for the family and host country institutions in establishing a climate of trust and a shared vision of the child's best interests. In a number of these cases the team failed in their attempts to act as mediators between the family, their values and their culture of origin and the values of host country institutions.

A review of the cases referred to the clinic revealed that few treatments ended in a formal disengagement from therapy with a concomitant administrative "closure" of a file. In general, treatment and outcome were considered to be an ongoing and interlocking process, with the child's symptoms being strongly influenced by the resolution of ongoing stressors including the reunification of families and the accordance of asylum. The imposition of further stressors, including the rejection of requests for asylum, led to a new reworking of treatment as families attempted to cope with this event. Parallel to the process of treatment was the child and their family's reformation of social ties during the resettlement process. As such, while patients no longer actively received treatment when their problems resolved, they were assured continued access to services should future needs arise. This also occurred for children who reached the age of majority while in treatment, who traditionally would have been considered ineligible for treatment at a children's hospital. As a result of their ongoing tenuous circumstances, efforts were made to remain available to these families in consultation to the adult service providers to whom they were referred.

Discussion

A review of the past four years of experience of the Montreal Children's Hospital's Transcultural Child Psychiatry Service reveals a specificity related to the clinic's clientele and to its methods of functioning and treatment. The clinic, by allowing a place for difference, has necessarily challenged the existing premises of mental health care practice (Rousseau, 1998). As such, the inscription of the clinic into the mainstream of mental health and social service institutions has introduced a tension within these institutions, as it has provoked a questioning of how services are presently organized, to whom and how services should be offered, and who are best seen to act as service providers to youth who are members of Montreal's non dominant cultural communities.

It is at this point that the team's presence provokes a paradox. While the Transcultural Child Psychiatry Clinic is situated within a tertiary care hospital and allowed to function beyond administrative and theoretical boundaries because of its superspecialization, the team's presence, philosophy and manner of function provokes a requestioning of this superspecialziation. Thus, part of the team's function has been its recognition of mainstream society's lack of knowledge of and of its failure to acknowledge and represent the knowledge, traditions and values of non dominant cultural communities within its institutions, whether formally or informally.

The clinic's position within a mainstream institution is proposed to be one that has the potential to be transformative. First, by its presence it hopes to provoke a transformation of institutions and methods of practice so that they better reflect present cultural and social realities. Secondly, by questioning hierarchies of knowledge and the construction of knowledge, the team hopes to question mainstream society's present medicalization of suffering, which has confined suffering within the categories of disease and disorder and which has resulted in an overemphasis of individual aspects of suffering with a neglect of its collective aspects. (Kleinman, Das & Lock, 1997).

References

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Kleinman A, Das V and Lock M (Eds.) (1997) Social Suffering. Berkeley: University of California Press.

Lacroix L. (1998) Revendication de l'identité chez une fillette sud-américaine adoptée: une démarche par l'art-thérapie. P.R.I.S.M.E. 8(3): 150-159.

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Rousseau C (1998). Se decéntrer pour cerner l'univers du possible: penser de l'intervention en psychiatrie transculturelle. P.R.I.S.M.E., 8(3):Ìý20-36.