(Appendix D)
The Transcultural Clinic (TC) at H么pital Jean-Talon Hospital was created in 1993 to respond to the needs of the large immigrant population in the hospital's catchment area. The clinic was established by Dr. Carlo Sterlin and other members of the Department of Psychiatry and received some infrastructure support from the hospital as well as small private donations. Six clinicians attached to the hospital formed the core staff. However, throughout its existence the clinic has relied on volunteers; 3/4 clinicians involved donate their services.
The clinic offers two types of outpatient service: (i) cultural consultations for professionals needing assistance in assessment and treatment planning; and (ii) time-limited treatment offered directly to patients of different cultural backgrounds. The clinic also provides training and community prevention and mental health promotion programs.
The clinic's therapeutic approach is strongly influenced by the French ethnopsychoanalytic approach originated by George Devereux (1970) and further developed by Tobie Nathan (1991) and Rose Marie Moro (Moro & Rousseau, 1998). The service uses two models, one using a small group with a principal therapist and two or three co-therapists, and the second involving a large group comprised of clinicians from different cultural backgrounds, culture brokers, and an interpreter, as well as members of the patient's entourage.
According to Nathan, the rationale for the large group method includes at least four distinctive features (Nathan, 1991; 1994, Streit, 1997):
- it reassures families in crisis who come from collectivist or communalistic societies who may find the group less threatening than a face to face dyadic clinical encounter
- it is an effective method to limit the problems of personal and cultural counter-transference
- through the intervention of the interpreter, it reduces the risk of misunderstanding the family
- the different perspectives, questions and interpretations of the multiple therapists provide a sort of "semantic bombardment" that unsettles the client, disengages them from their dominant systems of interpretation and mobilizes their capacity to explore new modes of interpretation and action.
Despite this rationale, this intervention strikes many as posing the threat of a power imbalance that would be unsettling to most patients. The only evaluations of this model to date have come directly from Nathan's group and have involved detailed analyses of cases. There has been no account of the experience of patients who receive this intervention. Accordingly, the aim of the present evaluation was to better understand the perspective of patients who received treatment at the Jean-Talon clinic with this extended group psychoanalytic model. The goal was to identify the acceptability and impact of the intervention from the patient's point of view.
Method
The sample comprised the 20 patients who had completed therapy at the clinic between November 1995 and September 2000. Based on earlier pilot work with a sample of 4 families, and interviews with clinicians, a semi-structured interview was devised to inquire about patients' experiences with the therapeutic intervention and its impact.
Findings
Of the 20 families seen by the service, 9 (45%) were traceable and agreed to the follow-up interview. While 5 found the group setting comfortable, 4 reported it made them uneasy. Five patients felt from the outset that the team was responding to their needs, while 4 only gradually came to trust the intervention as it unfolded over time. Most (8/9) of respondents appreciated the interventions and found the following aspects helpful: (i) it allowed them to express their suffering in their own language, (ii) it was useful to hear to proverbs that recalled their countries of origin (cf. Bagilishya, 2000); (iii) it was helpful to speak about their countries and personal history in an atmosphere of attentive listening and respect, which encouraged them to reflect on their past and consider how to refashion their future. Only one patient reported that the necessity to use an interpreter interfered with the creation of a proper rhythm of communication.
This initial evaluation of the impact of the large group ethnopsychoanalytic intervention is limited by the small sample size and the large number of non-respondents. However, it does suggest that the intervention is acceptable for some patients. Most patients did not find the group overly threatening and gradually came to see it as supportive and helpful. Patients' emphasis on the value of making links to their countries of origin, and between various proverbs, models and metaphors proposed by the clinicians and their own cultural experiences, supports some of the claims made for the specific efficacy of this type of therapy.
Despite the large team involved, the intervention remains cost effective because it enhances the therapeutic alliance and supports the active participation of the patient's network in the therapeutic process. In addition, some clinicians are willing to donate time on a voluntary basis to take part in this type of treatment because of the stimulation they receive from encountering multiple perspectives and because the team supports and facilitates their work with complex and challenging cases. The clinic also provides a unique setting for training and research. Future analysis of patients' experiences in therapy may help to assess the claims for the specific efficacy of the intensity and cultural diversity of the large therapy group.