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(Appendix C)

The ethnocultural profile of the population of children on the island of Montreal is changing rapidly. In 2000, more than 50% of children enrolled in schools in the metropolitan region were allophones. Health and social services as well as scholastic institutions have attempted to adapt to this demographic transformation but much remains to be done. Beyond the initial sensitization to cultural differences, there are few places of specialized practice that can serve the as training sites, consultation resources, and places to develop innovative practices.

The Transcultural Clinic of the Montreal Children's Hospital (MCH) has the triple mandate of training a diverse group of professionals form different disciplines (psychiatrists, physicians, psychologists, art therapists), clinical consultation and treatment, and ongoing research to rethink and renew clinical theory and practice through a critical examination of some of the implicit assumptions of conventional mental health care.

Objectives

The overall goals of the evaluation of the MCH program were to draw out the specificity and limits of a transcultural approach in child psychiatry and to outline the eventual contribution and the transferability of this specific vision to intervention in health, social service and school milieus. The specific goals were:

1. to describe the clinical population of the Transcultural Clinic and document the evolution of treatment modalities and outcomes;


2. to analyze the modes of conceptualization and intervention employed in complex cases of trauma and first episode psychosis followed by the clinic.

Methods

The evaluation of the MCH Transcultural team comprised three main elements:

1. An analysis of the characteristics of families requesting services and of the evolution of the clinical relationship. The clinic's clientele was described in terms of sociodemographic profile, reasons for consultation, referral sources and pre-migratory and post-migratory histories. The evolution of cases in terms of modalities of treatment and outcome was documented.


2. A qualitative retrospective analysis of the characteristics of the interventions of the MCH Transcultural Team focusing on case series with trauma or psychosis


3. A prospective evaluation of new cases, with longitudinal follow-up. Given the limited duration of the FASS project, the collection of data for this last component is not complete and will be the subject of later publications.

Quantitative analysis of cases

A quantitative analysis of 239 cases seen by this service between July 1996 and December 2000 was performed. Variables examined included the age and gender of the referred patient and their country of origin, and their reasons for referral and the referring source. Events considered to be specific to this patient clientele were documented. Finally, therapeutic process and modalities were noted, as well as outcome, as judged by the therapists involved.

Qualitative Analysis of Cases of Trauma or Psychosis

This aspect of the project used in-depth qualitative analysis of the clinical narratives of professionals and care providers about a limited number of cases in treatment for which the evolution over the last two years was known.

We chose 14 cases involving either trauma or psychosis, two types of diagnostic problems, frequently encountered by the team that are associated with contrasting assumptions about the relative contributions of environmental and constitutional factors. Trauma represents the impact of an adverse environment on the family and the child. In the case of families referred to the team, the role of organized violence is often major. We therefore find ourselves faced with problems where the macrosocial determinants (war and persecution) directly influence the microsocial reconstruction (family and community relationships) of the person. In the case of psychosis, professional models emphasize the role of genetic factors and constitutional vulnerability. The environment and the culture are often considered secondary, serving as a background for the reconstruction of meaning disrupted by the psychotic episode.

For both types of problem, we collected data from three sources: (1) an interview with the clinician responsible for the case; (2) a group interview including all members of the team involved in the follow-up and, if possible, with the outside care provider also involved in following the family; and (3) a review of the subsequent evolution of the cases studied as they were discussed in weekly team meetings over the period of the study.

Findings

Children from over 70 countries were seen by the clinic. Their countries of origin were diverse. A large proportion of referrals was received for children who had arrived form countries with recent and/or ongoing conflicts, including but not limited to Central and West Africa, North Africa, Central America, South and South East Asia and the former Soviet Union. The team also saw Canadian children from Aboriginal (First Nations and Inuit) communities. Transcultural issues relating to Aboriginal Canadian children's referrals included the experience of cultural upheaval by these communities and difficulties in providing culturally responsive services to these children by conventional health and social service providers.

In terms of the age of children referred, approximately one-third were between the ages of 5 to 9 years, one-third were between the ages of 10 to 14 years, 22% were between the ages of 15 to 18 years, and less than 15% were under 4 years of age. Two-thirds of the referrals were received for male children.

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. Certain types of referral reflected specific issues that posed particular challenges in the migrant population including requests for the evaluation of developmental delays and medical symptoms, as well as the evaluation and treatment of psychotic disorders and other symptoms, with the concomitant use of traditional treatment modalities. 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.

Certain aspects of the referral sources and methods of accessing the clinic were instructive. The clientele were less likely to be self-referred than to be referred by a helping professional already involved with the family (86% of cases). Referrals were received from multiple sources, including schools and health and social service providers in primary care clinics (CLSCs). 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. In addition, religious, health, legal and social service agencies who had developed an expertise in addressing the needs of this particular patient population also requested referrals. Finally, children were referred directly from the emergency room, as well as from outpatient clinics and from hospital wards. Efforts were made to meet referred patients at their inpatient wards within the hospital in order to help ensure follow-up.

The chief factor associated with continued follow-up appeared to be related to the family's means of accessing services. Families who were provided the clinic's name were more likely to follow-up if they called the team themselves and were able to discuss their request for services with the team secretary. At the initial evaluation an interpreter was present, who acted both as language interpreter and culture broker and as such was a key member of the treating team. Once the family had attended their first appointment, almost 3/4 remained in treatment.

Treatment offered differed in some aspects from conventional child psychiatric care. Often multiple treatment were proposed, with over a third of patients being offered two or more treatment modalities; this might include, for example, individual play or art therapy, medication for the child, family therapy, as well as mediation with schools, other health and social service providers and the Refugee Board. Aspects of the treatment approach distinctive to the team included the use of symbolic interventions based on a reformulation of the representations of individual and collective experience.

In general, treatment outcome was considered an ongoing process, with the child's symptoms being influenced by the resolution of ongoing stressors including the reunification of families, the accordance of refugee status or conversely, the elaboration of alternative living plans by the family, and the child and his family's adaptation to the host country and their formation of new social ties. As such, while clientele no longer received services and treatment was ended upon favorable outcome, the families were assured continued access to services if future needs arose. This also occurred for children who reached the age of majority and therefore no longer were eligible for children's services. 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. Similar efforts were made to remain available as consultants to primary care providers.

Outcome, as judged by therapist, was largely good (40% of cases) or moderate (24%). In some cases, treatment ended as a result of a refusal of a patient's request for asylum in Canada (6%). In 30% of cases where consultations were provided of where patients did not follow-up, there was no information available to judge outcome. Finally, poor outcome was noted in a small number of cases. In general, cases with poor outcome shared in common a burden of catastrophic stressors, with the additional component of a worsening of behavioral problems by the youth involved. This often occurred 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, with the transcultural team failing in their attempts to act as mediators between the family, their culture of origin and the host country institutions and values.

Analysis of trauma cases

The analysis of trauma histories revealed the coexistence of multiple versions of the traumatic history, which reflect different perceptions and interpretations of daily reality in the host country. This multiplicity of histories offered by the families (which may be provided by different members of a family or at successive moments of interaction) confronts the tendency for clinicians and host country institutions to search for a single authoritative truth, which has a reassuring rationality, and is conflated with the need for a coherent account for psychological reconstruction of the self.

The analysis of the evolution of cases allowed us to identify several elements that promote reconstruction after trauma:

1. One key element is the capacity for care providers and teams to support uncertainty and to orient themselves with partial truths, without trying to attribute to one or another version of the patient's history the full weight of "reality", but instead allowing some movement or fluidity between different histories, recognizing that each has the capacity to contain a dimension of experience. As well, our analyses suggest that too great a tendency to emphasize the pre-migratory traumatic experience of the family can minimize or hide other important problems that are ultimately related but more immediate. Shifts in the roles and dynamics of power in the family system often provide keys to the therapeutic process. Such opportunities can be quickly lost, however, when they are obscured by a traumatic history that, by its power to evoke horror and suffering, captures all the attention.


2. A second element is the necessity to put the notion of disclosure of trauma and victimization in social and cultural perspective. Disclosure of trauma is essentially perceived as positive and curative in the Euro-American mental health literature. Our results suggest that too great an emphasis on disclosure can be damaging and that respect for the rhythm of the individual and the family is preferable. This has direct implications for evaluation, which must be considered as a gradual process. The initial meeting between the team and the family establishes the possibility of a therapeutic alliance and a basis for further collaborative work. In no case can it provide complete understanding of the experience of the child or the family.


3. In the case of immigrant families, and particularly refugees, the articulation between therapeutic and political realms of experience is crucial to the possibility of any therapeutic alliance. The experience of discrimination and exclusion is common among people with minority status. In the case of refugees, the risk of deportation, the difficulty of continuing one's life in a social and legal vacuum, and the anguish associated with the decision making process of the Commission of Immigration for the Status of Refugees, gives primary importance to the political dimension.

The clinical team's firm commitment to the right of asylum was a necessary precondition for therapeutic interaction. This position challenges the neutrality that is often claimed by professionals. All would agree that the first step toward the resolution of trauma is ending the traumatizing situation and reducing the risk of its repetition. The recognition of the potential for trauma in political contexts that transcend the therapeutic frame represents an important step in the therapeutic process. The "neutrality" of the therapist, on the contrary, may reinforce the status quo, that is to say, the situation of mistrust in which the refugee must constantly prove that he has legitimate reasons to seek asylum.

Analysis of psychosis cases

In the case of psychosis, the transcultural team was involved first as consultants to the crisis team responsible for the care of hospitalized adolescents, and later at the level of direct outpatient follow-up treatment with families.

A review of cases of psychosis made it clear that transcultural intervention allowed the emergence of the plurality of explanatory models that coexist around a first psychotic episode. Since the hospital context tends to relegate non-medical explanatory models to a second level, families censure themselves. The establishment of an alliance that values pluralism and relativizes medical knowledge, facilitates the emergence of other discourses. The religious world, traditional knowledge, political relationships of domination in the host society, and the gap between biomedical values and those of the families' culture of origin, are then used to make meaning of psychotic disorganization and allow the family and community to support the afflicted person.

Being open to this plurality of perspectives also allowed the clinicians to grasp the importance of having recourse to multiple models of treatment, including non-medical approaches. Our data reveal, in particular, the increasing importance of transnational networks in providing access to traditional and religious treatment. Contrary to Euro-American modalities that center the problem on the psychotic adolescent, these approaches locate the etiology in external causes of significance to others in the family and community. This allowed family and community to gather around and support the adolescent.

Our results suggest that the transcultural intervention allows us to strengthen the alliance with the family, to enlarge the therapeutic space of possibilities, and to reconnect rather than isolate the psychotic person. This is accomplished essentially because of:

1. the exposure and validation of different explanatory models
2. the presentation of the medical model as one knowledge among others
3. the possibility of play between different models, as a function of family and intrapsychic dynamics, in a way that re-establishes a family homeostasis that gives a meaningful place to psychotic experience.

Discussion

The analysis of cases of trauma and psychosis provided evidence of how novel practices can emerge from questioning dominant models. This de-centering allows: (1) re-equilibrating the power relations in therapeutic interventions to give due recognition to the knowledge and experience of families and community; and (2) introducing polyvocality into the therapeutic space. This can enlarge the possibility of reconstructing the definition and meaning of the problem (traumatic history or first episode of psychosis) and also permit the gradual integration of painful experiences following a rhythm that is partly determined by the family.