contributors/

contributeurs :

Nazilla Khanlou
Laura Simich
Edward Ng
D. Walter Rasugu Omariba
Mengxuan Annie Xu
James Ted McDonald
Biljana Vasilevska
Laura Simich
Morton Beiser
Immigrant Mental Health
Ruth Marie Wilson
Rabea Murtaza
Yogendra B. Shakya
La sant mentale des immigrants
Alice W. Chen Introduction by/par :
Charmaine C. Williams Nazilla Khanlou, RN, PhD, OWHC Chair, Womens Mental Health Research,York University.
Joanna Ochocka Beth Jackson, PhD, Strategic Initiatives and Innovations Directorate, Public Health
Elin Moorlag Agency of Canada.
Sarah Marsh
Karolina Korsak
Baldev Mutta
Laura Simich
Amandeep Kaur
Kwame McKenzie
Emily Hansson
Andrew Tuck
Steve Lurie
Lin Fang
Miu Chung Yan
Shahlo Mustafaeva
Regan Shercliffe
Ginette Lafrenire
Lamine Diallo
Ccile Rousseau
Ghayda Hassan
Nicolas Moreau
Uzma Jamil
Myrna Lashley
Yvonne Lai
Michaela Hynie
Yogendra B. Shakya
Nazilla Khanlou
Tahira Gonsalves
Yuk-Lin Renita Wong
Josephine P. Wong
Kenneth P. Fung
Sepali Guruge
Enid Collins
Amy Bender
 59

Taking Culture Seriously in Community Mental Health:

A five-year Study Bridging Research and Action
Joanna Ochocka, Elin Moorlag, Sarah Marsh, Karolina Korsak,
Baldev Mutta, Laura Simich and Amandeep Kaur
Summer / t 2010
65

Improving Mental Health Services for Immigrant,

Refugee, Ethno-cultural and Racialized Groups
Kwame McKenzie, Emily Hansson, Andrew Tuck and Steve Lurie

70

3
Mental Health Service Utilization by Chinese
Immigrants: Barriers and Opportunities
Introduction: Immigrant Mental Health in Canada Lin Fang
Nazilla Khanlou and Beth Jackson
75
5
How Cultural Awareness Works
La sant mentale des immigrants au Canada: Miu Chung Yan
une introduction
79
Nazilla Khanlou et Beth Jackson

9
Development of a Culturally Sensitive Screening Tool:
Policy and Research Implications
Migrant Mental Health in Canada Shahlo Mustafaeva and Regan Shercliffe
Nazilla Khanlou
84
17
In the Interest of Working with Survivors of War,
Health Literacy, Immigrants and Mental Health Torture and Organized Violence: Lessons from a
Laura Simich University/Community Research Collaborative in
23
South-Western Ontario
Ginette Lafrenire and Lamine Diallo
Is there a Healthy Immigrant Effect in Mental Health?
88
Evidences from Population-Based Health Surveys in
Canada Du global au local: Repenser les relations entre
Edward Ng and D. Walter Rasugu Omariba lenvironnement social et la sant mentale des
29
immigrants et des rfugis
Ccile Rousseau, Ghayda Hassan, Nicolas Moreau, Uzma Jamil et Myrna Lashley
The Mental Health of Immigrants and Minorities
93
in Canada: The Social and Economic Effects
Mengxuan Annie Xu and James Ted McDonald Community Engagement and Well-Being of Immigrants:
33
The Role of Knowledge
Yvonne Lai and Michaela Hynie
A Review of the International Literature
98
on Refugee Mental Health Practices
Biljana Vasilevska and Laura Simich Determinants of Mental Health for Newcomer Youth:
39
Policy and Service Implications
Yogendra B. Shakya, Nazilla Khanlou and Tahira Gonsalves
Compassionate Admission and Self-Defeating
103
Neglect: The Mental Health of Refugees in Canada
Morton Beiser The Mental Health of Immigrant and Refugee
45
Children in Canada: A Description and Selected
Findings from the New Canadian Children and
Pre-Migration and Post-Migration Determinants of Youth Study (NCCYS)
Mental Health for Newly Arrived Refugees in Toronto Morton Beiser
Ruth Marie Wilson, Rabea Murtaza and Yogendra B. Shakya
108
51
Mental Health Promotion through Empowerment
Immigrant Access to Mental Health Services: and Community Capacity Building among East and
Conceptual and Research Issues Southeast Asian Immigrant and Refugee Women
Alice W. Chen Yuk-Lin Renita Wong, Josephine P. Wong and Kenneth P. Fung

55 114

Cultural Competence in Mental Health Services: New Working with Immigrant Women: Guidelines
Directions for Mental Health Professionals
Charmaine C. Williams Sepali Guruge, Enid Collins and Amy Bender
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Introduction:
Immigrant Mental Health in Canada
Beth Jackson is the Manager of Research and Knowledge Development in the Strategic Initiatives and Innovations Directorate at
thePublic Health Agency of Canada (PHAC). She holds a Doctorate in Sociology from York University (Toronto) and completed a
Post-doctoral Fellowship with the CHSRF/CIHR Chair in Health Services and Nursing Research in the Institute for Health Research
atYork University.
Nazilla Khanlou, RN, PhD, is the inaugural Ontario Womens Health Council (OWHC) Chair in Womens Mental Health Research in
theFaculty of Health at York University and an Associate Professor in its School of Nursing. Professor Khanlous clinical background
isin psychiatric nursing. Her overall program of research is situated in the interdisciplinary field of community-based mental health
promotion in general, and mental health promotion among youth and women in multicultural and immigrant-receiving settings
inparticular.

Its an exciting time in the mental health field. More (Khanlou); and data related to effects of discrimination
people are talking about the crucial role of mental health on mental health (Khanlou). Furthermore, McKenzie et
for the wellbeing of individuals, families, communities, al note that information on ethnocultural and racialized
and society. Through the efforts of international, groups could be enhanced in the Canadian Census, and
national, and local organizations, recognition of the Chen notes that sub-population analysis would be facili-
importance of mental health is gathering momentum. tated by the inclusion of reliable measures of immigration
While mental health often continues to be viewed status and ethnicity in health services administrative
through the lens of mental illness, growing conceptual databases. The research studies described in this issue
and empirical work is supporting the need for a broader employ a variety of research methodologies and tech-
understanding of the concept. This is clearly seen in the niques to fill some of these data gaps, including
contributions to this special issue on immigrant mental community-based participatory research strategies
health in Canada. (Ochocka et al; Shakya et al; Wilson et al), mixed-
This collection of articles illustrates a broad methods (qualitative and quantitative) designs (Wong et
spectrum of knowledge on migrant mental health, al), analysis of large-scale population surveys (Beiser,
building and assessing evidence from a variety of sources: Children; Ng & Omariba), and micro-econometric
clinical practice, community-based research, population analysis (Xu & McDonald). Each of these approaches
surveys and health surveillance. The articles address a makes an important contribution to knowledge about
range of conceptual, methodological and measurement immigrant and refugee mental health.
issues and identify key data and research gaps. Several The articles in this issue also address an array of
articles discuss the challenges of defining and operation- subpopulations, substantive issues, and intervention
alizing key concepts and dimensions of mental health approaches. Subpopulations addressed here include those
and service delivery, including the concept of mental identified by gender (Beiser, Refugees; Guruge et al), age/
health itself (Ochocka et al); access to care (Chen); life stageparticularly children and youth (Beiser,
culture (Yan); cultural diversity (Ochocka et al) and Children; Wilson et al; Shakya et al), immigration
cultural competence (Williams). The definition of these category (Beiser, Refugees; Wilson et al; Vasilevska &
terms has important material consequences for immi- Simich), country of origin (Fang; Mustafaeva & Shercliffe;
grants and refugees, shaping how they engage in, and are Wilson et al; Wong et al), racialized groups (McKenzie et
engaged by, mental health systems and services. al; Williams) and survivors of war, torture and organized
Researchers, policymakers, analysts and service providers violence (Lafrenire and Diallo). These subpopulations
also face a lack of culturally sensitive diagnostic tools and the researchers, policymakers, analysts and service
(Vasilevska & Simich; Mustafaeva & Shercliffe) and gaps providers who work with and for them are confronted
in: longitudinal data for immigrants and refugees (Beiser, with complex challenges and dynamics of racialized
Refugees); data related to women across a range of social discrimination (Chen; Fang; McKenzie; Rousseau et al;
locations (Guruge et al); data on older immigrants Williams), the acknowledgement and attainment of

3
 Nazilla Khanlou AND Beth Jackson

health literacy (Lai & Hynie; Ng & Omariba; Simich; The pan-Canadian contributions successfully draw from
Wong et al) and cultural competence (Guruge et al; cross-disciplinary collaborations and consider diverse
McKenzie et al; Vasilevska & Simich; Yan). dimensions of mental health.
While challenges and barriers are often the focus Upon reflecting on the articles included in this
of attention in research, policy and practice, there is important compilation of research on immigrant and
increasing consideration of individual and community refugee mental health, we find there are important
assets (e.g. resilience), the productive outcomes of questions for future research to consider. Some of the
community engagement, and the identification and questions are larger in scope (requiring longitudinal
dissemination of promising practices. Lai & Hynie, approaches) and others are more specific (and can be
McKenzie et al, and Khanlou, among others in this issue, localized to the particular settings in which immigrants
emphasize the need to account for the strength and resil- and refugees resettle in Canada):
ience of immigrants and refugees, shifting the focus of the How do gender, lifestage, migrant status, and social
discourse of mental health promotion and interventions position influence mental health during the early years
from needy clients to one that acknowledges the clients of resettlement and over time?
as resourceful participants in society who have been able What are the systems pathways to resilience versus vul-
to survive and thrive in very challenging circumstances. nerability across groups?
Community engagement in research, policy and program What are the best practices for individualized mental
development and service delivery is one way to build on health service delivery across settings (for example,
individuals and community wisdom and strengths. Lai & large urban settings with significant numbers of immi-
Hynie and McKenzie et al focus on the positive impact of grants compared to smaller urban setting with smaller
community engagement on mental health, and Wong et al representations of immigrants)?
demonstrate the successes of program development and What are the mental health needs of individuals and
delivery that integrate principles of social inclusion, access families without legal immigration status?
and equity. Promising practices such as those described What are the access barriers to mental health services
by Wong et al (and others in this issue) may be under- for refugee claimants?
taken at different, sometimes multiple and concurrent, How does the pre-migration context for Government
levels of intervention (from the social determinants of Assisted Refugees influence their post-migration men-
mental health, to mental health promotion, to clinical tal health?
treatment). Khanlou proposes a systems approach to What community educational strategies are effective in
mental health in migrant populations, and corresponding reducing stigma around mental health challenges and
micro-, meso- and macro-levels of analysis are demon- promoting early access to mental health care?
strated in the articles that follow (e.g. Ng & Omariba; How can advocacy strategies related to mental health
Vasilevska & Simich). Building on this systemic approach, and well being be integrated across sectors to enhance
several articles in this issue identify key principles or the resettlement experience of immigrant populations?
success factors for promising practices. Fang recom- We believe this special issue of research will
mends multi-faceted, multi-level interventions that contribute to the momentum in mental health promotion
engage individuals, practitioners, families, and communi- and open up opportunities for collaborative and cross-
ties. Even micro-level clinical treatment interventions can sectoral work in mental health practice, public policy,
adopt a community-based focus (Lafreniere & Diallo). pedagogy and research among those working with and
Reaffirming the potential transformative effect of for immigrant and refugee populations in Canada.
community engagement, Wong et al identify collective
empowerment and capacity building (via peer leadership
training and outreach) as key to building a sustainable
mental health promotion program.
This special issue will push forward our under-
standing of the complex dynamics involved in promoting
the mental wellbeing of diverse groups of immigrants
in Canada. The articles collectively add to our knowledge
of the social, economic, cultural, and multi-systems
context of immigrant mental health. Of significant
importance are the intersections of the resettlement
context and immigrant status with mental health and
well being that are considered throughout the articles.

4
la sant mentale des immigrants
au Canada: UNE INTRODUCTION
Beth Jackson est gestionnaire de Recherche et dveloppement des connaissances la Direction des politiques stratgiques et de
linnovation de lAgence de la sant publique du Canada (ASPC). Elle est titulaire dun doctorat en sociologie de lUniversit York
(Toronto) et elle a complt titre de boursire une recherche postdoctorale auprs de la chaire FCRSS/IRSC de recherche en services
de sant et en soins infirmiers de lInstitute for Health Research de lUniversit York.
Nazilla Khanlou, IA, Ph. D., est la premire titulaire de la chaire du Conseil ontarien des services de sant pour les femmes (COSSF)
en recherche sur la sant mentale des femmes de la Facult des sciences de la sant de lUniversit York et elle est aussi professeure
agrge son cole de sciences infirmires. Lexprience clinique de la professeure Khanlou est en soins infirmiers psychiatriques.
Ses recherches portent sur le domaine interdisciplinaire de la promotion de la sant mentale dans la collectivit en gnral, et sur
la promotion de la sant mentale auprs des jeunes et des femmes dans les milieux qui accueillent des immigrants en particulier.

Il sagit dune priode palpitante pour le domaine de diffrences culturelles font aussi dfaut aux chercheurs,
la sant mentale. Davantage de gens discutent du rle aux dcideurs, aux analystes et aux fournisseurs de
crucial de la sant mentale au regard du bien-tre des services (Vasilevska et Simich; Mustafaeva et Shercliffe)
personnes, des familles, des collectivits et de la socit. qui connaissent galement des lacunes en ce qui
Grce aux efforts dorganisations internationales, concerne : les donnes longitudinales sur les immigrants
nationales et locales, la reconnaissance de limportance et les rfugis (Beiser, Refugees); les donnes relatives
de la sant mentale prend de lampleur. Mme si la sant aux femmes selon diverses origines sociales (Guruge et
mentale continue dtre aborde sous langle de la coll.); les donnes sur les immigrants plus gs (Khanlou);
maladie mentale, des travaux conceptuels et empiriques et les donnes relatives aux effets de la discrimination
sont de plus en plus nombreux souligner le besoin de sur la sant mentale (Khanlou). En outre, McKenzie et
comprendre le concept dune faon plus large. Cela se coll. soulignent que linformation sur les groupes ethno-
reflte clairement dans les articles de ce numro spcial culturels et raciaux pourrait tre amliore dans le
sur la sant mentale des immigrants au Canada. Recensement du Canada. Par ailleurs, Chen mentionne
Les articles mettent en vidence un large spectre de que lanalyse des sous-populations serait facilite par
connaissances au sujet de la sant mentale des immi- lajout de mesures fiables du statut dimmigrant et de
grants, accumulant et valuant des lments de preuve lappartenance ethnique dans les bases de donnes
tirs de sources diverses : pratique clinique, recherche au administratives des services de sant. Les recherches
sein des collectivits, sondages mens auprs de la popula- prsentes dans le prsent numro utilisent diverses
tion et surveillance mdicale. Les articles abordent une mthodes et techniques de recherche pour pallier
gamme de questions conceptuelles, mthodologiques et certaines de ces lacunes relatives aux donnes ;
de mesures, et cernent les lacunes cls au regard des y compris des stratgies de recherche participative
donnes et de la recherche. Plusieurs articles portent sur au sein de la collectivit (Ochocka et coll. ; Shakya
les difficults rencontres au moment de dfinir et et coll.; Wilson et coll.), des mthodes mixtes (qualitative
doprationnaliser les dimensions et les concepts cls et quantitative) (Wong et coll.), des analyses de
de la sant mentale et de la prestation de services, y sondages grande chelle de la population (Beiser,
compris le concept de sant mentale lui-mme Children; Ng et Omariba) et des analyses microconom-
(Ochocka et coll.) ; daccs aux soins (Chen) ; de triques (Xu et McDonald). Chacune de ces approches
culture (Yan); de diversit culturelle (Ochocka et contribue de faon importante lenrichissement des
coll.) et de comptence culturelle (Williams). La dfini- connaissances concernant la sant mentale des immi-
tion de ces termes a des consquences concrtes grants et des rfugis.
importantes pour les immigrants et les rfugis en Les articles de ce numro touchent galement
faonnant comment ils abordent les systmes et les une srie de sous-populations, de questions de fond
services de sant mentale et comment ils sont reus par et dapproches dintervention. Les sous-populations
ceux-ci. Des outils diagnostiques tenant compte des abordes ici comprennent celles classes selon le sexe

5
 Nazilla Khanlou et Beth Jackson

(Beiser, Refugees; Guruge et coll.), lge/ltape du cycle de cls, ou des facteurs de russite, des pratiques prom-
vie en particulier les enfants et les jeunes (Beiser, etteuses. Fang recommande des interventions aux niveaux
Children; Wilson et coll.; Shakya et coll.), la catgorie et aux facettes multiples qui font appel aux personnes, aux
dimmigration (Beiser, Refugees ; Wilson et coll. ; praticiens, aux familles et aux collectivits. Les interven-
Vasilevska et Simich), le pays dorigine (Fang; Mustafaeva et tions de traitement clinique de microniveau peuvent
Shercliffe; Wilson et coll.; Wong et coll.), les groupes raciaux adopter une approche fonde sur la collectivit (Lafrenire
(McKenzie et coll. ; Williams) et les survivants et Diallo). En raffirmant leffet transformateur potentiel
de la guerre, de la torture et de la violence organise de lengagement communautaire, Wong et coll. identifient
(Lafrenire et Diallo). Ces sous populations et les lautonomisation et le renforcement des capacits des
chercheurs, dcideurs, analystes et fournisseurs de services collectivits (au moyen du la formation en leadership entre
qui travaillent avec eux ou pour eux sont confronts des pairs et relations communautaires) comme tant essen-
difficults complexes et aux dynamiques de la discrimina- tiels la cration dun programme durable de promotion
tion raciale (Chen; Fang; McKenzie; Rousseau et coll.; de la sant mentale.
Williams), la reconnaissance et lacquisition des connais- Ce numro spcial poussera plus loin notre
sances gnrales en sant (Lai et Hynie; Ng et Omariba; comprhension des dynamiques complexes en jeu dans la
Simich; Wong et coll.) et la comptence culturelle (Guruge promotion du bien-tre mental des divers groupes
et coll.; McKenzie et coll.; Vasilevska et Simich; Yan). dimmigrants au Canada. Collectivement, les articles
Mme si les difficults et les obstacles sont ajoutent notre connaissance du contexte social,
souvent au cur de lattention de la recherche, des poli- conomique, culturel et multisystmique au regard de la
tiques et de la pratique, on considre de plus en plus les sant mentale des immigrants. Les intersections entre le
atouts individuels et collectifs (la rsilience, par exemple), contexte de rtablissement, le statut dimmigrant et la
les rsultats positifs des engagements communautaires et sant mentale et le bien-tre qui sont examines tout au
lidenti fication et la dissmination des pratiques prom- long des articles sont dune importance significative. Les
etteuses. ce sujet, Lai et Hynie, McKenzie et coll., et contributions pancanadiennes tirent profit avec succs de
Khanlou, entre autres, insistent sur la ncessit de rendre collaborations interdisciplinaires et examinent diverses
compte de la rsilience des immigrants et des rfugis, dimensions de la sant mentale.
changeant laccent du discours sur lintervention et la Aprs avoir rflchi au sujet des articles de cette
promotion de la sant mentale de clients ncessiteux importante compilation de recherches sur la sant
on en vient reconnatre que les clients sont des partic- mentale des immigrants et des rfugis, nous constatons
ipants ingnieux dans la socit qui ont t en mesure de quil existe des questions importantes que des recherches
survivre et de russir dans des circonstances trs difficiles. futures devront examiner. Certaines de ces questions
Lengagement communautaire dans la recherche, llabo sont de porte plus vaste (ncessitant des approches
ration de politiques et de programmes et dans la longitudinales) et dautres sont plus prcises (et peuvent
prestation de services constitue une faon de btir sur les tre situes dans les milieux particuliers o les immi-
forces et la sagesse des personnes et des collectivits. Lai grants et les rfugis se rtablissent au Canada) :
et Hynie, McKenzie et coll. mettent laccent sur les Comment le sexe, ltape du cycle de vie, le statut
consquences positives de lengagement communautaire dimmigrant et la position sociale influencent-ils la sant
sur la sant mentale. Wong et coll. dmontrent, quant mentale au cours des premires annes de la rinstalla-
eux, les succs de llaboration et de la prestation de tion et au fil du temps?
programmes qui intgrent les principes de linclusion Quelles sont les voies systmiques vers la rsilience,
sociale, de laccs et de lquit. Les pratiques prom- plutt que vers la vulnrabilit, chez les divers groupes?
etteuses, comme celles dcrites par Wong et coll. (et par Quelles sont les pratiques exemplaires pour la prestation
dautres chercheurs ayant contribu au prsent numro) de services individualiss en matire de sant mentale
peuvent tre appliques divers niveaux dintervention selon le milieu (par exemple, les grandes villes comptant
(dterminants sociaux de la sant mentale, promotion de un nombre lev dimmigrants comparativement aux
la sant mentale, traitement clinique) ; et parfois petites villes o les immigrants sont moins nombreux)?
plusieurs niveaux simultanment. Khanlou adopte une Quels sont les besoins en matire de sant mentale des
approche par systmes au regard de la sant mentale personnes et des familles sans statut dimmigrant lgal?
dans les populations migrantes et les niveaux danalyse Quels sont les obstacles laccs aux services en matire
(micro-, mso- et macro) sont mis en vidence dans les de sant mentale pour les demandeurs dasile?
articles qui suivent (p. ex. Ng et Omariba; Vasilevska et Chez les rfugis pris en charge par le gouvernement,
Simich). En sappuyant sur cette approche systmique, comment le contexte avant la migration influe-t-il sur la
plusieurs articles du prsent numro cernent des principes sant mentale aprs la migration?

6
 la sant mentale des immigrants au Canada: UNE INTRODUCTION

Quelles stratgies ducatives communautaires sont

efficaces pour rduire les prjugs entourant les difficul-
ts en matire de sant mentale et pour promouvoir un
accs rapide aux soins?
Comment des stratgies relatives la sant mentale et le
bien-tre peuvent-elles tre intgres entre les secteurs
pour amliorer lexprience de rinstallation des popula-
tions immigrantes?
Nous croyons que ce numro spcial contribuera
soutenir llan dans le domaine de la promotion de la
sant mentale et quil ouvrira des possibilits de travaux
intersectoriels mens en collaboration au sujet des
pratiques, des politiques publiques, de la pdagogie et de
la recherche en matire de sant mentale pour les
personnes travaillant avec et pour les immigrants et les
rfugis au Canada.

7
8
MIGRANT MENTAL HEALTH IN CANADA1
Nazilla Khanlou, RN, PhD. OWHC Chair in Womens Mental Health Research. Associate Professor, Faculty of Health, York University

DEFINING MENTAL HEALTH, SOCIAL DETERMINANTS that foster supportive environments and
OF MENTAL HEALTH, AND MENTAL HEALTH PROMOTION individual resilience, while showing
Our mental health is a vital component of our respect for culture, equity, social justice,
wellbeing. The World Health Organization (WHO) interconnections and personal dignity
defines mental health as a state of wellbeing in which the (Centre for Health Promotion, 1997).
individual realizes his or her own abilities, can cope with MHP models and approaches grounded in majority-
the normal stresses of life, can work productively and culture based research, however, may be limited in that
fruitfully, and is able to make a contribution to his or her they do not necessarily take into account multiple
community (WHO, 2007). According to WHO (2007) cultural, linguistic, and systemic barriers to maintaining
without mental health there is no health. This state of and promoting mental health in the post-migration and
wellbeing arises from interactions between the individual resettlement context. Understanding, developing, and
and his or her environment (Khanlou, 2003). implementing specific MHP principles and strategies offer
The health and mental wellbeing of migrant popula- important opportunities for enhancing the mental
tions is influenced by complex and interrelated factors. wellbeing of diverse segments of society.
According to Ornstein (2002), the social determinants of This policy brief addresses the mental health of
health, which are the socio-economic conditions that migrant populations in Canada. Several caveats are
influence the health of individuals, communities and brought to the readers attention. First, the focus of this
jurisdictions, affect both physical health and mental policy brief is on mental wellbeing with a particular
health. While the health of migrant populations can be emphasis on the social determinants of migrant mental
influenced by similar dimensions of social determinants health. The policy brief applies a mental health promotion
as that of mainstream Canadians, additional determi- perspective, rather than a psychiatric or biomedical
nants due to their migrant status (e.g. social and approach in considering the mental wellbeing of migrant
economic integration barriers, access barriers to relevant populations. Psychiatric and biomedical perspectives
social and health services due to language and cultural provide invaluable information in relation to mental
differences, lack of social networks) also may exert signifi- illness of individuals. And, support for practice and policy
cant influences. Some argue that the migration and are needed, which address accurate diagnosis, effective
settlement process itself is a significant social determi- treatment, follow-up, and rehabilitation for migrants who
nant of health (Meadows, Thurston, & Melton, 2001). have acute or chronic mental illness. These, however, are
Pre-migration contexts also affect subsequent post- not the focus of the literature review for this policy brief.
migration health outcomes. In cases of war-torn home Second, our notion of immigrant/migrant is not a
countries, for instance, post-traumatic stress disorder may monolithic one. We have attempted to distinguish
be a potential health risk that needs addressing in the between the categories of immigrants, refugees, and those
post-migration context. In the case of family separations, with no legal status (or precarious status). However,
mental health risk factors may be exacerbated. Those who within each of these categories are many diversities. In
have migrated to Canada as the only economic hope for a order to recognize the intersections of gender, cultural
larger family in the country of origin, bear a tremendous background, racialized status, lifestage, and other influ-
burden to be economically successful (Preliminary ences, we have applied a systems approach to organizing
findings, Khanlou, Shakya, and Muntaner, CHEO, 2007- the findings from the literature review and considered the
2009; Eiden, 2008). micro, meso, and macro level factors influencing migrant
There is growing attention towards both the concep- mental health.
tual and practical aspects of mental health promotion
(Khanlou, 2003). Mental Health Promotion (MHP) is, MENTAL HEALTH OF MIGRANT POPULATIONS
the process of enhancing the capacity In health research, the impact of migration on the
of individuals and communities to take health and well-being of migrants has been described
control over their lives and improve their through three dominant approaches. In the first approach,
mental health. [MHP] uses strategies the hypothesis is that newly arrived immigrants have

9
 Nazilla Khanlou

worse health than the general population. This approach Individual influences
is referred to as the morbidity-mortality hypothesis. A
second approach, referred to as the healthy immigrant Age
effect, proposes that immigrants tend to have better The age at which people migrate can have an
health than the general population (Hyman, 2004; Alati et important impact on their subsequent health status.
al. 2003). The final approach, referred to as the transi- Limited research has been conducted on the impact of
tional effect, suggests that the health advantage that migration on mental wellbeing from a lifestage perspective.
immigrants demonstrate upon arrival decreases the Children who migrate at a very young age (or may
longer they live in the country (Alati et al., 2003). even have been born here), may not experience great
While these conceptualizations of immigrant differences in their health status in comparison to their
health have greatly influenced current research in this Canadian-born counterparts. However, studies show
area, they have been predominantly based on the health that structural or macro factors such as barriers to
and well-being of immigrants and refugees arriving education and employment (such as their parents faced)
through mainstream migration channels. In addition, (Portes & Rumbaut, 2005) may continue to be potential
due to the distinct pre-migration experiences of immi- mental health stressors. More research is still required
grants and refugees, their health and wellbeing can be in this area.
significantly different in the post-migration settlement Adolescents have both specific challenges as well as
context, requiring recognition of the differences between resiliencies in the post-migration context (Khanlou et al.,
the two groups of migrants (Khanlou, 2008b). A third 2002; Khanlou & Crawford, 2006). Caught between their
group, migrants with no legal status, face additional own identity development and having to mediate the new
systemic challenges in the post-migration context. For culture for their parents, youth often take on roles far
these individuals, their non-status gives them and their beyond the capacity of their actual age (Preliminary
families limited or no access to health care, education, findings, Khanlou, Shakya, and Muntaner, CHEO, 2007-
social services and legal rights required to promote and 2009). Female refugee youth in particular, face settlement
protect their health (Omidvar & Richmond, 2003; and migration challenges that may put them at added risk
Mulvihill, Mailloux, & Atkin, 2001). Recognizing the for negative mental health outcomes, given the often
above differences, we use the term migrant as an inclusive traumatic pre-migration contexts they are coming from
one, which includes immigrants, newcomers, refugees, and the post-migration identity development they have to
refugee claimants and/or individuals with precarious contend with (Khanlou & Guruge, 2008).
immigration status. The immigrant elderly face their own set of chal-
In order to examine the research evidence on lenges, specifically around isolation and abuse, language,
migrant mental health and implications for policy, a culture, and mobility (Hasset and George, 2002; Guruge,
systems approach has been applied here. A systems Kanthasamy, and Santos, 2008). Further research is also
approach fits well with the underlying premises of MHP. required in this area.
The approach allows for a multi-layered examination of
factors influencing the mental wellbeing of migrants. The Gender
findings of the review have been organized along indi- Gender is a significant influence on health status and
vidual, intermediate, and systems levels of influences and intersects with other influences. Because women often
experiences, in line with previous findings on migrant migrate as dependents of their male relatives, their unique
mental health (Khanlou, 2008b; Khanlou et al, 2002). migration trajectories and specific health needs are often
Individual (micro level) influences address individual not incorporated into policy formulation, the focus being
attributes such as age, gender, and cultural background. on male migrants (Guruge & Collins, 2008; Mawani,
Intermediate (meso level) influences are those that link 2008) thereby undermining their access to healthcare
individuals to their social context such as family and services (Oxman-Martinez et al., 2005).
social support networks, and acculturation. Systems Gender and age as intersecting variables create an
(macro level) influences are in relation to the broader added layer of complexity for post-migration contexts,
social and resettlement context such as economic where adolescent women face different barriers than
barriers, appropriate services, access to healthcare, and their male counterparts, and younger migrants also have
experiences of discrimination and racism. Micro, meso, different challenges than older ones. Women with
and macro level influences intersect and interact, influ- precarious status are also at risk of being exploited and
encing migrant mental health. subject to unsafe or unclean working environments.
Women with no legal status may have family members
who depend on their income and are therefore unwilling

10
 MIGRANT MENTAL HEALTH IN CANADA

and unable to report exploitative work practices (Guruge accord with the reality of immigrant families lives. The
& Collins, 2008). specific needs of a potential immigrant, and the impor-
tance of extended family members needs also to be taken
Cultural background, spirituality and into consideration (Canadian Association for Community
religious identity Living, 2005).
Mental health services that attempt to fit migrants into Social support networks outside of the family tend to
categories of western clinical knowledge, do not capture the revolve around the ethnic community, and religious orga-
cultural and spiritual or religious factors that may be nizations that cater specifically to that ethnic community.
involved in migrant mental health (James & Prilleltensky, Some mosques for instance, while not formally connected
2002; Collins, 2008). Research in ethnically diverse cities has to settlement programs, provide informal assistance to
shown that spirituality and cultural context often construct newcomers from legal advice, to employment skills, to
mental health and mental illness in very different ways explanations of cultural difference (Preliminary findings,
(Fernando, 2003; Collins, 2008; Across Boundaries). Keeping Khanlou, Shakya, and Muntaner, CHEO, 2007-2009).
this in mind, western models of mental health promotion While social support can mean different things to
can be supplemented by culturally-specific programs different people within communities, Simich et al., (2005)
(Khanlou, 2003; Khanlou et al., 2002).2 reported common forms of social support as identified by
Religion in particular plays an important role in the policy makers and service providers, which include: infor-
lives of different groups of immigrants, and their religious mational, instrumental, and emotional supports (Simich
affiliations may even be strengthened post-migration, et al., 2005: 262). In order to provide different levels and
whether for reasons of renewed religious belief in the types of support, there must be an attempt made towards
context of marginalization of religious identities, or holistic coordination of services (Simich et al., 2005). The
because religious institutions become locations of perceived impact of social support on the wellbeing of
community support (Preliminary findings, Khanlou, immigrant communities is also significant (Simich et al.,
Shakya, and Muntaner, CHEO, 2007-2009; for the impor- 2005) and must be connected to the broader social deter-
tance of religious education, see: Zine, 2007). minants of health, discussed below.
Many of the studies reiterate the importance of
understanding these individual factors within an inter- Acculturation
secting or systems framework. Other factors that also Acculturation is a process whereby contact between
require attention within the policy and practice context different cultural groups results in changes in both groups
are migrants who face barriers due to their differing (Berry, 2001). Acculturation is premised on the existence
abilities/ disabilities, and those who experience marginal- of ethnic, cultural, and or national identities. Studies have
ization both from mainstream society and in-group shown that, being able to balance a sense of ethnic
ethnocultural communities due to their different sexual identity with adaptation into the new society can lead to
orientation(s). Little or no Canadian research has positive mental health outcomes (Berry, 2008). In other
examined the impact of othering and discrimination on words, ethnic identification with a particular group, in the
the mental health of these migrants. context of a multiethnic society, can become a protective
factor leading to well being. In some cases, strength of
Intermediate influences ethnic identification may lead to higher risk of psycholog-
ical distress, as when the community of identification is
Family and social support networks negatively stereotyped within the broader society. Beiser
The family and social networks of migrants can be and Hou (2006), in their study of Southeast Asian Boat
an important source of support in the resettlement People, found that if a particular group experiences
context and promote mental wellbeing. Research findings discrimination or perceives discrimination they may be at
reveal that immigrants tend to rely first and foremost on higher risk for psychological distress. This is because
extended family members (especially those who have been experiences of discrimination will serve as reminders of
in the country longer) for settlement related needs and marginalized status for ethnic minorities. There are other
also for a social support network (Preliminary findings, variables, such as language, which produce different
Khanlou, Shakya, and Muntaner, CHEO, 2007-2009). results in terms of mental health and well being (Beiser &
While Canadian immigration policy previously encour- Hou, 2006). Overall, however, cultural, ethnic, and
aged family reunification (Government of Canada, spiritual identifications, as well as community belonging
Immigration Act, 1978), in reality, this is difficult for are considered to be important factors in fostering
refugees or those with precarious status. The ways in positive mental health (Canadian Institute for Health
which family is defined in legislation, may not always Information, 2009).

11
 Nazilla Khanlou

Systems influences ethno-specific service delivery models vs. culturally

sensitive mainstream service delivery models).
Economic barriers
Economic hardship is a significant determinant of Migration status and access to healthcare
health and linked to health disparities. One of the most Migration status influences access to healthcare.
significant stressors for mental health identified by immi- Immigrants and refugees have various challenges, but
grants is the underemployment or unemployment that may at least in theory be able to access healthcare
they must deal with upon arrival. Economic barriers to services. Those with precarious status however (Oxman-
integration became significant sources of stress in immi- Martinez et al., 2005) are often caught in liminal spaces
grants lives, affecting their families. Immigrant youth of incertitude (McGuire & Georges, 2003), which leave
often internalize the frustration of their parents and this them particularly vulnerable to negative mental health
in turn affects their own performance in school (Khanlou, outcomes. Those with no legal status are at even greater
Shakya, & Muntaner, CHEO, 2007-2009). On the other risk, as they simply may have no recourse to health
hand, some research also indicates that even though services (Khanlou et al., manuscript in progress).
foreign-born immigrant children are more than twice as The pre-migration experiences of refugees can also
likely to live in poor families, they show lower levels of have lasting impact on their mental health status after
emotional and behavioural problems (Beiser et al., 2002). migration. In general, newcomers may have different
This may in part be due to the fact that hardship is health status than their Canadian born counterparts and
expected by immigrants when they first come to the over time this can deteriorate (Alati et al., 2003; Beiser,
receiving country and the hope is that their situation will 2005). Ali (2002) found that newer immigrants exhibit
improve over time (Beiser et al., 2002; CHEO op cit). fewer mental health problems, when compared to their
However, if poverty persists, this can have negative effects Canadian-born peers, but it is not clear whether this is
on a childs IQ, school performance and lead to behav- the result of a greater resiliency in the immigrants or a
ioural problems (Beiser et al., 2002). difference in how they understand and conceptualize
mental health problems (Ali, 2002: 6). Further longitu-
Appropriate services dinal research needs to be conducted to see to what
At the larger societal level, culturally sensitive and extent health status remains unaltered.
specific mental health services prove to be the best
approaches towards positive mental health outcomes. Prejudice, discrimination and racism
Despite the best intentions, services remain underused While it may be difficult to measure racism, percep-
when formulated without a contextual understanding of tions of racism have been found to have an effect on
the clients they are intended for (Whitley et al., 2006; mental health (McKenzie, 2006), and subsequent service
Hasset & George, 2002; DesMeules et al., 2004; Newbold, utilization by immigrants (Whitley et al., 2006). Racial-
2005). Services must also account for the fact that immi- ized immigrants face barriers of discrimination, prejudice
grants are not a monolithic or homogeneous group and and racism, based on their skin colour, accents, and
their heterogeneities are significant enough to warrant sometimes cultural differences (Simich et al., 2005).
new delivery models, based on the age, gender, cultural Experiences of prejudice and discrimination affect
differences and immigration status of clients. immigrant youths sense of belonging and psychosocial
Service agencies and organizations tend to be integration to Canada (see Khanlou, Koh, & Mill, 2008).
oriented towards giving information on paper or through Research continually shows connections between
the Internet, however, a verbal exchange is often the most systemic discrimination, underemployment or unemploy-
effective way to provide information about services to ment and mental health outcomes (McKenzie, 2006;
newcomers (Khanlou, Shakya, & Muntaner, CHEO, 2007- Raphael, Curry-Stevens, & Bryant, 2008; Mawani, 2008).
2009). Research suggests that ethnic media may also be a In summary, migrant mental health is influenced
better way to reach specific populations (Simich et al., by a multitude of factors, and requires an understanding
2005), given language barriers. in the context of their intersections (Khanlou et al.,
Organizations and agencies (governmental and non- 2002; Oxman-Martinez et al., 2005), which has policy
governmental) need to continue their coordination efforts implications.
and avoid working in silos (CHEO, op cit.) and research
needs to continue on the long-term health outcomes of POLICY RECOMMENDATIONS
immigrants. In addition, research is required into Beiser (2005) observes that prevailing paradigms
examining the effectiveness and efficiency of different towards immigrants affect health policy. Conceptual
mental health service delivery models (for example, approaches to studying immigrant health also need to

12
 MIGRANT MENTAL HEALTH IN CANADA

account for not just multiple factors as variables, but also provide public education campaigns directed at diverse
how and under what circumstances different influencing groups of migrants on the mental health system (acute
factors may be activated (Bergin, Wells, & Owen, 2008). and community based) and how to access appropriate
Traditional paradigms that have been used to explain services;
immigrant health (such as the healthy immigrant effect or provide standardized and quality monitored education
the morbidity-mortality paradigm) need to be re-examined to cultural interpreters; and
(Dunn & Dyck, 2000) in light of longer term outcomes provide education to health and social service providers
and the heterogeneity of immigrants along the lines of and students on culturally competent mental health
gender, age, immigrant status, and the historical pre- promotion.
migration context from which they come (Alati et al.,
2003; Beiser, 2005; Salant, 2003). Recommendation:
While subgroups of migrants such as refugees or Support policies that remove barriers to economic
those with precarious status are at greater risk of mental and social integration of newcomers (for example through
health problems (Khanlou & Guruge, 2008; McGuire & recognition of previous training and education).
Georges, 2003; DesMeules et al., 2005; Oxman-Martinez et
al., 2005; Simich, Wu, & Nerad, 2007), the resilience and Recommendation:
resourcefulness of immigrants also needs to be factored Support longitudinal and comparative research
into the analysis (Simich et al., 2005; Khanlou, 2008a; on migrant mental wellbeing that considers the multiple
Waller, 2001). This has specific policy implications, as the determinants of migrant mental wellbeing through
discourse needs to also shift from the focus on immigrants interdisciplinary approaches and community-academia
as needy service recipients (Simich et al., 2005: 265), to a alliances.
recognition of their capacity to survive in the face of
tremendous challenges. This shift in attitudinal focus has CONCLUSION
practical consequences for the ways in which employers Over two decades have passed since the publication
will see potential newcomer employees. If newcomers are of the report of the Canadian Task Force on Mental
looked upon as adaptable and resilient, rather than being Health Issues Affecting Immigrants and Refugees in
the cause of social problems (Simich et al., 2005), then their Canada (Beiser, 1988). Community-based and govern-
opportunities in the workforce may increase. mental initiatives attest to the progress we have made,
The following policy recommendations arise out of a though more intersectoral work needs to occur.
mental health promotion approach and recognize the While Canada has built a reputation as a leader in
inter-relations between micro, meso and macro levels of health promotion, it is the only G8 country that does not
influence on migrant mental wellbeing: yet have a mental health strategy. It is estimated that $23
billion is spent annually in medical bills, disability, and
Recommendation: sick leaves in Canada (Globe and Mail, July 25th page A4).
Support intersectoral approaches to promoting Mental health, a crucial part of overall health, must
migrant wellbeing across systems (including health, become a policy priority in Canada. There are positive
social services, resettlement, education, etc) through steps already being taken in this direction. In a 2006
developing, enhancing, and coordinating partnerships report to the Standing Senate Committee, the honour-
between sectors. able Michael Kirby recommended that a mental health
commission be set up in Canada. In 2007, the federal
Recommendation: government committed $10 million for two years and
Support integrated community-based mental health $15 million per year for two subsequent years (up to
services that: 2010) towards the establishment of the Mental Health
address the social determinants of migrant mental Commission of Canada (Office of the Prime Minister,
health; http://pm.gc.ca/eng/media.asp?id=1807). The Govern-
are gender and lifestage sensitive; and ment has also confirmed an amount of $130 million over
recognize both the challenges and resiliencies of diverse 10 years to the Canadian Mental Health Commission
groups of migrants (newcomers, immigrants, refugees, (Health Canada, 2008).
precarious status). In January 2009 the Commission released its
Toward Recovery and Well-Being: A Framework for a
Recommendation: Mental Health Strategy for Canada as a draft summary
Support education and training towards providing for public discussion. In 2009 the Canadian Institute for
the following: Health Information also released its document entitled

13
 Nazilla Khanlou

Improving the Health of Canadians 2009: Exploring Beiser, M. (1988). After the door has been opened: Mental
Positive Mental Health. On 12 February 2009 the health issues affecting immigrants and refugees in Canada.
Pan-Canadian Planning Committee for the National Report of the Canadian Task Force on Mental Health Issues
Think Tank on Mental Health Promotion released its Affecting Immigrants and Refugees. Minister of Supply and
document, Toward Flourishing for All National Mental Services Canada.
Health Promotion and Mental Illness Prevention Beiser, M., and Hou, F. (2006). Ethnic identity, resettlement
Policy for Canadians. Media features and conferences stress and depressive affect among Southeast Asian refugees in
are also addressing the gaps around the public Canada. Social Science and Medicine, 63, 137-150.
discussion of mental health and mental illness in Canada.
The Globe and Mail featured a series on Canadas Beiser, M., Hou, F., Hyman, I., & Tousignant, M. (2002). Poverty,
family process, and the mental health of immigrant children in
Mental Health Crisis, (http://www.theglobeandmail.
Canada. American Journal of Public Health, 92(2), 220-227.
com/breakdown). A conference (held in Toronto, 4-6
March 2009) in conjunction with the Mental Health Bergin, M., Wells, J.S.G., and Owen, S. (2008). Critical realism: a
Commission of Canada focused on mainstreaming philosophical framework for the study of gender and mental
mental health and wellness promotion (http://www.clif- health. Nursing Philosophy, 9, 169-179.
fordbeersfoundation.co.uk/toronto.htm).
Berry, J.W. (2008). Acculturation and adaptation of immigrant
Such initiatives are very timely and are contributing youth. Canadian Diversity. Vol. 6. No. 2, 50-53.
to mental health promotion efforts. Attention is also
needed on specific sub-groups of the population, such as Berry, J.W. (2001). A Psychology of Immigration. Journal of
migrants. In light of the stigma around mental illness, and Social Issues, Vol. 57, No. 3, 615-631.
barriers to accessing mental health services for migrants,
Canadian Association for Community Living. (2005). Immigra-
mental health promotion efforts need to consider how tion and Disability submission to the Standing Committee on
best to reach diverse audiences. We hope that this policy Citizenship and Immigration, April, 2005.
brief will be a timely contribution to the broader
movement towards the creation of a national mental Canadian Institute for Health Information. (2009). Improving
health strategy, an educational tool to create awareness of the Health of Canadians: Exploring Positive Mental Health.
mental health promotion for migrant communities, and Ottawa: Canadian Institute for Health Information.
an impetus for specific policy initiatives promoting the Centre for Health Promotion. (1997). Proceedings from the
mental wellbeing of migrant populations in Canada. We International Workshop on Mental Health Promotion. Univer-
believe that such initiatives will have benefits both for the sity of Toronto. In C. Willinsky, and B. Pape. (1997). Mental
specific populations they are targeted at as well as health promotion. Social Action Series. Toronto: Canadian
communities and Canadian society at large. Mental Health Association National Office.

Collins, E. (2008). Recognizing Spirituality as a Vital

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E. (Eds). (2008). Working with Immigrant Women: Issues and
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Newbold, B. (2005). Health status and health care of immigrants
Khanlou, N. et al., Manuscript in Progress. Social determinants in Canada: A longitudinal analysis. Journal of Health Services
of non-status migrant womens health. Research and Policy, Vol 10, No. 2, 77-83.

15
 Nazilla Khanlou

Office of the Prime Minister. (2007). Mental Health Commis- World Health Organization (WHO). (2007). Mental health:
sion of Canada Media Backgrounder. Available URL: http:// Strengthening mental health promotion. Fact Sheet # 220.
pm.gc.ca/eng/media.asp?id=1807 Available URL: http://www.who.int/mediacentre/factsheets/
fs220/en.
Omidvar, R., & Richmond, T. (2003). Immigrant settlement and
social inclusion in Canada. Toronto, Canada: Laidlaw Foundation. Zine, J. (2007). Safe havens or religious ghettos? Narratives of
Islamic schooling in Canada. Race, Ethnicity and Education,
Ornstein, M (2002). Ethno-Racial Inequality in the City Vol. 10, No. 1, 71-92.
of Toronto: An Analysis of the 1996 Census. Retrieved
6th October 2006 from URL: www.city.toronto.on.ca/diversity/
pdf/ornstein_fullreport.pdf

Oxman-Martinez, J, Hanely, J, Lucida, L, Khanlou, N, Weeras- FOOTNOTES

inghe, S, & Agnew, V. (2005). Intersection of Canadian policy
parameters affecting women with precarious immigration 1
This article presents a shortened version of a policy brief
status: a baseline for understanding barriers to health. Journal of written for the Public Health Agency of Canada and the
Immigrant Health, 7(4), 247-258. Metropolis Project. The policy brief was commissioned and
funded by the Strategic Initiatives and Innovations Directorate
Pan-Canadian Planning Committee for the National Think (SIID) of the Public Health Agency of Canada. Support for its
Tank on Mental Health Promotion. (2009). Toward Flourishing development was provided both by SIID and the Metropolis
for AllNational Mental Health Promotion and Mental Illness Project. The opinions expressed in this publication are those of
Prevention Policy for Canadians. Available online: http://www. the authors and do not necessarily reflect the views of the
utoronto.ca/chp/mentalhealthpdf/National%20Mental%2 Public Health Agency of Canada or Metropolis. The full policy
Hea lt h%2 0Promot ion%2 0 a nd%2 0Ment a l%2 0I l l ness%2 0 brief can be found at: http://canada.metropolis.net/events/
Prevention%20-%20Best%20Adviceon%20a%20Policy%20 health/health_seminar.html.
for%20Canadians.pdf
2
Being aware of and addressing the unique cultural needs of
Portes, A., and Rumbaut, R.G. (2005). Introduction: The Second different groups is at times referred to as cultural competence.
Generation and the Children of Immigrants Longitudinal Study. Some argue that cultural competence can in fact further
Ethnic and Racial Studies, Vol. 28, No. 6, 983-999. marginalize and separate culturally different others, and that
a more appropriate framework is one based on anti-racism and
Raphael, D., Curry-Stevens, A., and Bryant, T. (2008). Barriers to
anti-oppression. While debates continue around this issue,
addressing the social determinants of health: insights from the
most agree that diverse individual needs must be addressed in
Canadian experience. Health Policy In Print, doi:10.1016/j.
mental health service delivery, as Canadas population is not
healthpol.2008.03.015.
homogeneous.
Salant, T., and Lauderdale, D.S. (2003). Measuring culture: a
critical review of acculturation and health in Asian immigrant
populations. Social Science and Medicine. 57, pp. 71-90.

Simich, L., Beiser, M., Stewart, M., and Mwakarimba, E. (2005).

Providing social support for immigrants and refugees in
Canada: Challenges and directions. Journal of Immigrant
Health. Vol. 7. No. 4, 259-268.

Simich, L., Wu, F., and Nerad, S. (2007). Status and health
security: an exploratory study of irregular immigrants in
Toronto. Canadian Journal of Public Health. (98) 5, pp. 369-373.

Waller, M.A. (2001). Resilience in ecosystemic context:

Evolution of the concept. American Journal of Orthopsychiatry,
71(3), 290-297.

Whitley, R., Kirmayer, L., and Groleau, D. (2006). Under-

standing immigrants reluctance to use mental health services: a
qualitative study from Montreal. Canadian Journal of Psychi-
atry. (51) 4, pp. 205-209.

16
Health Literacy, Immigrants
and Mental Health1
Laura Simich, Ph.D. is Scientist in Social Equity and Health Research at the Centre for Addiction and Mental Health, Toronto;
Assistant Professor in the Department of Psychiatry and the Department of Anthropology, University of Toronto; and Health and
Wellbeing Domain Leader at the Ontario Metropolis Centre. An anthropologist with expertise in qualitative methods and community-
based research, her research focuses on sociocultural determinants of mental health among immigrants and refugees and aims
to inform policy and promote community mental health.

abstract
This article defines health literacy and its implications for immigrants in Canada. Existing evidence about health literacy, health
outcomes, language proficiency, gender and social and cultural barriers that affect immigrants health literacy is noted. Mental health
literacy, stigma and culture are discussed. The article concludes with suggested health literacy interventions.

Acknowledgements:
This summary article is based on a literature review conducted for a policy brief with support from the Public Health Agency of Canada
20082009. In addition, support to CAMH for salary of scientists and infrastructure has been provided by the Ontario Ministry of Health
and Long Term Care. The views expressed [here] do not necessarily reflect those of the Ministry of Health and Long Term Care. The
author also acknowledges the research assistance of Farah Mawani and Alessandra Miklavcic.

Good mental and physical health, defined simply as International literacy surveys, such as the Interna-
feeling good and functioning well in daily life, is a key tional Adult Literacy and Skills Survey (IALSS), have
outcome of successful immigrant settlement and integra- assessed individual and collective health literacy skills
tion. Newcomers to Canada must obtain new information in the areas of health promotion, health protection,
about health issues and services while experiencing disease prevention, healthcare maintenance and system
resettlement stress and often new health needs. Health navigation (Canadian Council on Learning 2007, 2008).
literacy describes the ability to obtain, process, under- Three basic levels of health literacy skills have been
stand and use health information to make appropriate identified: the first, involving reading and numeracy, the
decisions about health (Ad Hoc Committee 1999). There second, interactive skills, i.e., knowing how to converse
are many definitions of health literacy, but the most clear with a busy health professional about symptoms and
and comprehensive definition includes the ability to seek concerns and a third, critical health literacy, describing
information, learn, appraise, make decisions, communi- the ability to analyze and use health information to
cate information, prevent diseases and promote exert greater control over life situations. From this
individual, family and community health (Rootman, perspective, health literacy is seen as a right and an
Frankish, and Kaszap 2007). Current definitions of health issue of equity and citizenship (Nutbeam 2000;
literacy encompass a critical understanding of health Kickbusch, Wait and Maag 2005).
issues and knowledge of how to use the health care system The basic idea behind health literacy appears
(Nutbeam 2000), and emphasize the responsibility of straightforward: the greater a persons ability to learn
health and educational institutions to smooth the about health, the better that persons health. But health
two-way communication process and help people obtain literacy is not just a personal ability or a one-way process
needed health care (Nielsen-Bohlman, Panzer and Kindig that depends upon the individuals linguistic proficiency
2004). According to the Canadian Public Health Associa- or comprehension of written information such as a
tion, attention should be paid to health literacy among doctors prescription. Rather, it is a complex, multidimen-
immigrants because these are areas in which immigrants sional communication process that also involves
are especially disadvantaged (Rootman and Gordon-El- health-care providers competencies, the legibility of the
Bihbety 2008). health care system for diverse groups and appropriate

17
 Laura Simich

policy and programs to achieve effective communication (Zanchetta and Poureslami 2006). While existing
(Kickbusch et al. 2005). Health literacy is a complex inter- evidence demonstrates that immigrants experience many
action that goes beyond reading; it is affected by linguistic and cultural barriers in accessing health care in
education, culture, and language (Nielsen-Bohlman et al. Canada (Bowen 2001; Gagnon 2002), we still do not know
2004). Immigrants arrive in Canada having had different enough about how social and cultural barriers actually
health and health care experiences and knowledge of affect health literacy or health outcomes. Although more
health issues in their homelands. The resettlement experi- research is needed, there is sufficient evidence to suggest
ence involves cultural adaptation, which produces new practical ways to enhance immigrants health literacy
health challenges as well as new opportunities for skills, including using clear and multiple forms of
knowledge exchange about health in family life, schools, communication, community-based development and
neighbourhoods and the workplace. Enhancing health delivery methods and increasing cultural competence in
literacy therefore applies not only to medical settings, but providers of health and social services.
also to a variety of settings across ones life span and
throughout settlement and integration. Language Proficiency, Gender and
Health Literacy
Health Literacy and Immigrants in Canada Despite the high educational levels of many immi-
Results of the IALSS, which surveyed 23,0000 grants and refugees, it is not surprising that health
Canadians, showed that 60% of adults in Canada lack the literacy levels are low in the early years of settlement. As
capacity to obtain, understand and act upon health infor- the 2003 IALSS results show, about 60% of immigrants
mation and services and to make appropriate health fell below Level 3 in prose literacy (considered the
decisions (Canadian Council on Learning 2007). Health minimum level for coping with the demands of everyday
literacy is a strong predictor of overall health status and life and work in a knowledge economy) compared to 37%
self-reported health status is, in turn, a reliable indicator for the Canadian-born population (Canadian Public
of health outcomes. Canadians with the lowest health health Association 2006, 27). The IALSS estimated that
literacy scores are 2.5 times as likely to perceive them- 32% of foreign-born women have extreme difficulty with,
selves as being in fair or poor health compared to those and only limited use of printed materials compared to
with higher health literacy scores. This statistical relation- 24% of foreign-born men and approximately 10% of
ship holds even after removing the impact of age, gender, Canadian-born women and men (Rootman and Gordon-
education, mother tongue, immigration and Aboriginal El-Bihbety 2008,17). Immigrant womens lower levels of
status (Canadian Council on Learning 2008). health literacy can have a wide impact on information
There is cause for concern because low health exchange about health and help-seeking for immigrant
literacy may have a long-term impact on population communities because women often play a central care
health. Those individuals with lower literacy skill levels giving role in families and other social networks. Longitu-
are 1.5 to 3 times more likely to experience negative dinal research with Southeast Asian immigrants in
health outcomes and difficulties managing chronic Canada identified English fluency as a significant determi-
diseases, although it is difficult to disentangle the effects nant of both depression and employment, particularly for
of poor literacy and poor access to health care (DeWalt, immigrant women (Beiser and Hou 2001), and found that
Berkman, Sheridan, Lohr and Pignone 2004). Other when women participate in formal language training they
outcomes of low literacy and health literacy include lower benefit more than men.
income and less community engagement--outcomes that Analysis of the Longitudinal Survey of Immigrants
are also associated with poorer health and quality of life. to Canada (LSIC) has shown that self-reported poor
These outcomes may affect disproportionately recent health was significantly related to lack of improvement
immigrants who are not well established. Recent immi- in language proficiency over time for both immigrant
grants, those with lower levels of education and with low men and women (Pottie, Ng, Spitzer, Mohammed and
French or English proficiency, seniors and people Glazier 2008). This finding has implications for increasing
receiving social assistance tend to have lower levels of the availability of language training as well as improving
literacy and health literacy (Rootman and Gordon-El- health care for immigrants. A lack of affordable English
Bihbety 2008, 21). or French as a Subsequent Language (ESL or EFL)
Barriers to health literacy, such as lack of meaningful programs for adults is a barrier for newcomers to
multilingual information about health issues, knowledge Canada who wish to improve their literacy and health
of where to find the right health care or how to access literacy skills, which in turn promote social integration
preventive services contribute to the deterioration in and wellbeing. Without basic literacy skills, new immi-
health status of immigrants in Canada over time grants have difficulty becoming health literate enough to

18
 Health Literacy, Immigrants and Mental Health

manage health-relevant information within the context ally diverse groups (Fung, Andermann, Zaretsky, A. and
of the Canadian health system (Rootman and Gordon- Lo 2008; Guruge and Collins 2008). There is also growing
El-Bihbety 2008, 26). recognition that safe and effective mental health care
requires the provision of trained cultural or community
Structural and Cultural Barriers to interpreters (Abraham and Rahman 2008).
Health Literacy
Common sense suggests that providing written Mental Health Literacy, Stigma and Culture
information alone is not enough to ensure good health. Mental health literacy poses particular challenges.
The social and cultural context in which information is Lack of public awareness about mental health and stigma
exchanged, ways of communicating and the timing of against people suffering from mental illness are wide-
health information also matter. Information about spread problems in Canada (Bourget and Chenier 2007);
employment, housing and other immediate needs are new policies and program initiatives are required to meet
often priorities in the early years in Canada; however, these challenges (Standing Senate Committee 2006).
information about health is one of the top needs of Mental health literacy may be defined as knowledge and
longer established immigrants (Caidi 2007). Immigrants beliefs about mental disorders which aid their recogni-
report more barriers to health care than non-immigrants tion, management or prevention (Jorm 2000). It entails
and perceive that existing health services and informa- knowledge and beliefs about mental health disorders that
tion are not sensitive to the cultural, faith, language or emerge from general pre-existing belief systems. Lack of
literacy needs of diverse communities. Barriers identified mental health literacy results in delays in seeking appro-
by immigrants include fear of speaking English; priate treatment and creates difficulties communicating
suspicion of authority; isolation and sense of being an with health professionals. Lay people generally have a
outsider; reliance on children (who may have inadequate poor understanding of mental illness. They are unable to
experience and language proficiency themselves) to find identify mental disorders, do not understand what causes
accurate information; lack of familiarity with Canadian them, are fearful of those who are perceived as mentally
information sources; cultural differences; and absence of ill, have incorrect beliefs about treatment, are often
knowledge of how to ask for services (Caidi 2007). reluctant to seek help for mental disorders and are not
Factors that affect health literacy for immigrants may sure how to help others (Canadian Alliance on Mental
include, but are not limited to, language proficiency, Illness and Mental Health 2008).
prior education about health issues in the country of The Canadian Alliance on Mental Illness and Mental
origin, cultural beliefs about illness, familiarity with the Health has identified immigrants as a priority group for
health care system in Canada and perceptions of cultural mental health literacy interventions. New Canadians
awareness among health service providers and institu- tended to identify life stress, such as the challenges of
tions. When service providers think of health literacy cultural adaptation, as the primary cause of mental health
only in narrow terms of verbal skills during their inter- problems (Canadian Alliance on Mental Illness and
actions with immigrants, the social and cultural context Mental Health 2008, 21). Although immigrants in general
of communication is neglected and the meanings of tend to suffer from depression and alcoholism in lower
important messages are lost. proportions than Canadian-born citizens (Ali 2002), the
Consideration of cultural diversity in health literacy early years after resettlement are especially stressful. For
has to extend beyond language to a broader appreciation many immigrants, resettlement stresses such as discrimi-
of cultural values, help-seeking beliefs and community nation and underemployment experienced after arrival in
engagement. Most health care providers have a very Canada add substantially to the risks of experiencing
limited understanding of immigrants and refugees expe- psychological distress (Beiser 2005). Moreover, many
riences and special health needs. Often the first need is refugees have acute unmet needs for mental health care
not primarily medical, but the need to improve trust, because of traumatic pre-migration experiences. The
comfort and communication, which highlights the problem comes not from the health of newcomers, but
two-way nature of health literacy as a social process and from the fact that immigrants and refugees have less
an agent to help break down structural and cultural access to mental health information and services when
barriers (Anderson Scrimshaw, Fullilove, Fielding, they need them. Newcomers may not be familiar with
Normand and the Task Force on Community Preventive formal mental health services, not only due to a lack of
Services 2003; Vissandjee and Dupere 2000; Weerasinghe mental health care in some countries of origin, but also
2001). Some mental health care practitioners in Canada due to linguistic barriers and lack of culturally appro-
are also raising awareness and developing professional priate mental health promotion and services in Canada
training about how to work with immigrants and cultur- (Beiser, Simich and Pandalangat 2003; James and

19
 Laura Simich

Prilleltensky 2003). In some languages, there are no developed a photonovella about nutrition as a health
specific equivalent terms for mental illnesses (Littlewood literacy tool with ESL-speaking immigrant women
1998), and talking about them may be considered taboo. (Nimmon 2007). The British Columbia Health Literacy
To overcome the negative impact of stigma in immigrant Research Team has carried out projects focusing on Farsi-
communities, it is necessary as a first step to talk more speakers (Poureslami, Murphy, Nicol, Balka and Rootman
openly about mental health in collaboration with commu- 2007) and is currently looking at ways to help Spanish-
nities and to increase mental health literacy through speaking immigrants develop health literacy skills.
community-based education (Simich, Maiter, Moorlag Health literacy initiatives targeting mental health
and Ochocka 2009). and immigrants are still rare, but one popular resource
Culture is of particular interest with regard to produced by the Centre for Addiction and Mental Health
mental health literacy because there are significant with funding from Citizenship and Immigration Canada
cultural variations in how people recognize, explain, in Ontario is the booklet, Alone in Canada: 21 Ways to
experience and respond to mental disorders. People in all Make it Better. This booklet has been used widely in ESL
cultural groups experience depression, but they may talk language classes in Ontario since 2002. The content for
about it differently (Jadhav, Weiss and Littlewood 2001). Alone in Canada, which focuses on ways for newcomers
Their mental health experiences are often closely to adapt and to reduce mental distress during settlement,
connected to social support, expectations about how was developed in each target language by focus groups of
others will respond and to fear of shame and social immigrants and refugees who shared their personal expe-
isolation, which can delay help-seeking (Lauber, Nordt, riences and coping strategies. The content was written in
Falcato and Rossler 2004). Current research on mental plain language, translated and edited by ethnolinguistic
health with ethnocultural and immigrant groups in community experts and again verified by community
Canada, however, suggests that they would like greater focus groups (Simich, Scott and Agic 2005). Alone in
access to mental health information that is community- Canada is available in 18 languages in print and on line at
based and culturally responsive (Simich et al., 2009). www.camh.net and at www.settlement.org. Also available
online from CAMH are a number of other resources:
Health Literacy Interventions multilingual educational fact sheets about mental health
for Immigrants and addictions problems, including the types of problems
Health literacy interventions appear to help coun- and what contributes to them, information on asking for
teract factors such as poverty, unequal access to quality help when things are not right and on coping with stress.
health services, lack of preventive health care and cultur- CAMH fact sheets can be found at: http://www.
ally and linguistically relevant health services. In general, camh.net/About_Addiction_Mental_Health/Multilin-
using participatory educational methods for learners to gual_Resources/index.html.
identify and learn about health issues results in an
improvement to most aspects of health literacy (King
2007). Shohet and Renaud (2006) distinguish three
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Longer versions of this article were published in 2009 as a
1

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Technology 2006. Out of the Shadows at Last: Transforming Contact, the journal of TESL Ontario.

22
Is there a Healthy Immigrant Effect
in Mental Health? Evidences from
Population-Based Health Surveys
in Canada
Edward Ng is a senior analyst with the Health Analysis Division at Statistics Canada. He obtained his Ph.D. in Social Demography
(theUniversity of Western Ontario), and has since worked in various research areas at Statistics Canada. His recent research interests
are on micro-simulation of cancers, diabetes hospitalization risk, as well as on immigrant health.
Walter Omariba holds a Ph.D. in Sociology (University of Western Ontario) and completed two years of post-doctoral training insocio-
economic determinants of population health at McMaster University. He is currently a Social Science Researcher at Statistics Canada.
His research interests are population health and social demography, and the application of advanced statistical techniques tounder-
stand health inequalities and contextual and structural influences on health.

abstract
This article presents a review of recent studies based on Statistics Canadas health surveys to examine the mental health of immigrants
and its changes over time, and documents factors found to influence mental health. The article concludes with a discussion on recent
developments in data collection at Statistics Canada and how the data can shed light on immigrant mental health.

Introduction depression or substance abuse. These studies have

Immigration has increased the diversity in Canada typically focused on specific sub-groups of immigrants
over the past 40 years. According to the 2006 census, such as refugees or recent immigrants from various
recent immigrants (those arriving within the last five war-torn parts of the world (Ali 2002). Because mental
years) mainly came from Asia (58%), followed by Europe health of immigrants is emerging as an important issue in
(16%) (Chui et al. 2007). The corresponding figures were Canada (Khanlou 2009), there is a need to have an overall
drastically different in 1971 at 11% and 61% respectively. picture of it at a population level.
Immigrants, especially those from the non-traditional This article has three objectives. First, it reviews
sources such as Asia and Africa, may face adjustment selected studies based on population-based health surveys
challenges because many of these are visible minorities from Statistics Canada to establish whether the healthy
who come from countries with cultures and languages immigrant effect at arrival and its loss over time extends
very different from those of Canada. The difficulties asso- to the mental health.3 Second, we report on important
ciated with settling in a new country are likely to affect factors found to influence mental health for the overall
the mental health of immigrants. and/or immigrant populations. Lastly, we highlight recent
Past studies on immigrant health mostly found a developments in data collection within Statistics Canada
health advantage among immigrants to Canada, possibly a that can potentially shed light on various aspects of
result of strong selection factors.1 However, these studies immigrant mental health.
also found a loss in this advantage over time in several
standard health measures including self-reported health Insights on Immigrant Mental Health from
(Chen et al. 1996a; Newbold and Danforth 2003; Ng et al. Statistics Canadas Health Surveys
2005), self-reported chronic disease (Prez 2002; With the implementation of the various cycles of
McDonald and Kenndy 2004), self-reported disability large population-based health surveys such as the
(Chen et al. 1996a; Chen et al. 1996b), and mortality National Population Health Survey (NPHS from 1994 to
(Wilkins et al. 2008).2 Previous research on immigrant present) and the Canadian Community Health Survey
mental health in Canada, however, has found that immi- (CCHS from 2000 to present), Statistics Canada has
grants experienced high level of psychiatric disorders, provided health practitioners, researchers and policy

23
 Edward Ng and D. Walter Rasugu Omariba

makers the information to understand immigrant mental Canadian-born. This study also found a country of origin
health at the population level.4 In this short article, we effect whereby the rates of depression and alcohol depen-
review selected research work on the healthy immigrant dence were both lower among those from Africa and Asia.
effect in the area of mental health, based on a systems The country of origin effect is highly related to the recency
approach used by Khanlou (2009) which allows for multi- of arrival effect, as those from Africa and Asia were most
layered analysis. Specifically, we look at how each of the likely to be recent immigrants.
studies reviewed considers the influences at the indi- Even after taking into consideration the differences
vidual, intermediate and systemic levels. Table 1 shows in individual influences such as age, sex, marital status,
the three levels used to organize the factors influencing income and education, and by other factors at the inter-
mental health. First, individual factors include age mediate or systemic levels such as language barriers, sense
(including the age at immigration), gender, cultural back- of belonging or employment status, recent immigrants
ground and religious identity. Second, intermediate were still found to have the lowest risk for both depression
factors include family, social support networks, and accul- and alcohol dependence. These results are consistent with
turation. Third, the systemic level includes economic the healthy immigrant effect at arrival and the conver-
barriers, appropriate services, healthcare access, gence toward the Canadian norm over time.
prejudice, discrimination and racism. This article also provided insights into factors that
Our search of literature yielded four articles on influence mental health for the overall population which
immigrant mental health studies based on Statistics includes immigrants. At the individual level, compared to
Canada Health Survey data with a focus on healthy females, males were less likely to have a depressive
immigrant mental health effect. Table 2 summarizes the episode, but were much more likely to have alcohol depen-
comparison of the four research works reviewed. First we dence. The study also shows, for both sexes, a gradient by
review the work by Ali (2002) published by Statistics household income and educational level for both depres-
Canada on mental health of immigrants, followed by sion and alcohol dependence, that is, the higher the
other studies conducted by researchers who used Statis- socioeconomic status, the lower the risk of having mental
tics Canada health surveys to examine explicitly the health issues. At the intermediate level, those with a sense
healthy immigrant effect in terms of mental health (Lou of belonging to local community also had a lower risk of
and Beaujot 2005; Wu and Schimmele 2005; Bergeron, both depression and alcohol dependence. Finally, at the
Auger and Hamel, 2009). systemic level, those who held a job were less likely than
1. Using the Canadian Community Health Survey those who did not to have depression.
(2000 CCHS cycle 1.1),5 Ali (2002) examined mental health 2. Lou and Beaujot (2005) used the cycle 1.2 of the
in terms of depression and alcohol dependence, and found Canadian Community Health Survey (2002)6, which had
that 8% of Canadians aged 12 or older reported symptoms as its focus mental health. Their analysis confirmed a
suggesting that they had at least one major depressive healthy immigrant effect and the decline in health for
episode within the 12 month before the survey interview. longer term immigrants. Mental health was measured in
For those born in Canada, the rate was 8%, while the corre- this study through a self-reported measure, where fair
sponding rate for immigrants was statistically lower, at 6%. and poor are defined as poor mental health, in response
In fact, immigrants were found to have lower rates in both to the question: In general, would you say your mental
depression and alcohol dependence than the Canadian- health is Excellent/Very good/Good/Fair/Poor? The
born population, with this healthy immigrant effect being proportion of poor mental health of the Canadian-born
strongest among recent immigrants. On the other hand, and foreign-born populations were 7% and 6% respec-
long-term immigrants had similar depression rates as the tively. Recent immigrants have a statistically significant

Table 1: Systems Approach Framework on Factors Influencing Mental Health of Migrants*

Level Factors (examples) Details
Individual (micro) age, sex/gender, cultural background, Children (including the age at immigration),
religious identity adolescents, the elderly
Intermediate (Meso) family, social support networks, acculturation Informational, instrumental and emotional
Cultural, ethnic and spiritual
Systemic level (Macro) economic barriers, appropriate services, Unemployment and underemployment
healthcare access by migration status, Based on age, gender, cultural differences
prejudice, discrimination and racism. and immigration status
Immigrants, refugees and those with precarious status
* based on Khanlou (2009)

24
 Is there a Healthy Immigrant Effect in Mental Health? Evidences from Population-Based Health Surveys in Canada

Table 2: Summary Table of Review of Recent Articles using Statistics Canada Dataset
to Study the Healthy Immigrant Effect in terms of Mental Health.
Ali (2002) Lou and Beaujot (2005) Wu and Schimmele (2005) Bergeron et al. (2009)
Nature of the study Statistics Canada Research report Research published in academic journal Research published in
Health Report article funded by Health public health journal
Canada
Dataset used CCHS 1.1 CCHS 1.2 NPHS cycle 2 CCHS 3.1
Mental health 1. Depression Self-rated poor 1. Depressive symptoms Self-rated mental
outcome(s) examined 2. Alcohol dependence mental health 2. E
 xperience of major depressive episode health
Target population Overall population Over population Overall population Immigrant population Overall population
Selected key factors found to be statistically significant based on the systems approach
framework on factors influencing mental health of migrants (Khanlou, 2009)
Individual level age age age age at immigration Results not presented
sex sex sex (under 18)
marital status marital status marital status other results not
income income income presented
education education education
country of origin self-reported poor health
(physical) health chronic conditions
life dissatisfaction race/ethnicity
self-reported children under 6
underweight rural residence
self-reported ability
to handle demand
Intermediate level language barriers social support social support results not None
sense of belonging sense of belonging to social contact presented
local community
number of friends
and relatives
Systemic level employment status lack of fit between None None
occupation and
education
Healthy immigrant Yes Yes Yes Yes for visible
mental effect and its minority recent
loss over time immigrants only
(confirmed or not)

advantage of 4% compared to 7% for those who had weak sense of belonging to local community, fewer close
arrived more than five years before the survey. They friends and relatives at the intermediate level; and the
argued that the variation in immigrant mental health may lack of fit between occupation and education at the
be explained by selection factors as well as the structural systemic level. Specifically, compared with people having
strain theory at the macro level or stress theory in the higher education, but working in less professional
micro level.7 Although various demographic and socio- occupations, those working in occupations that match
economic, stress and coping factors were significantly their high education level have lower risk of reporting
associated to self-reported poor mental health, immi- poor mental health.
grants still maintained a mental health advantage over 3. Using cycle 2 of the National Population Health
non-immigrants even after taking the structural strain Survey (NPHS 1996/97), Wu and Schimmele (2005)
and stress factors into consideration. examined changes in depression among immigrants over
The selected factors from all levels were found to be time.8 They measured depression as the number of depres-
significantly related to poor mental health. These include sive symptoms and experience of major depressive
young age, female gender, being previously married episode (MDE). Their analysis confirmed the healthy
(widowed, separated or divorced), low education or immigrant effect and loss in health advantage over time:
income, poor self-reported health, life dissatisfaction, visible minority immigrants were especially mentally
being underweight, self-reported poor ability to handle healthy, and that depression among immigrants was
demand at the individual level; lack of social support, found to increase soon after arrival.

25
 Edward Ng and D. Walter Rasugu Omariba

This study also found individual factors such as visible minority recent immigrants. Further research
being female, low family income, lower education, having would be needed to affirm these observations.
children under 6, marital status (separated/divorced, A few common limitations of all these studies can be
widowed, never married compared to married/cohabita- observed. First, since these studies used surveys that are
tion) to be significantly related with depression. At the collected at one point in time, the examination of the
intermediate level, the study found social support and healthy immigrant effect is not ideal. Although the study by
social contact to be protective factors against depression, Wu and Schimmele was based on the NPHS which has a
while at the systemic level whether one was employed or longitudinal component, it used only data at one time point.
not did not seem to matter. Longitudinal surveys that follow a cohort of individuals
An interesting finding here is the age of migration over time can better handle the transition from good to
effect; people who immigrated young (less than age 18) poor health (e.g. Ng et al. 2005). Second, previous
had a higher risk of depression. The authors reasoned that immigrant mental health research tends to focus on
the pressures for young immigrants to fit in at school and refugees or immigrants from various war-torn parts of the
in the new social environment can create potentially world based on sub-group specific survey (e.g. Noh et al.
stressful conflicts between the values and norms present 1999). In contrast, none of the studies based on Statistics
in their homes and those learned in school and social life. Canadas health surveys we reviewed focused on refugees or
Others may explain this by way of various structural or conducted the analysis by immigration class. This is mainly
macro factors such as barriers to education and employ- because immigrant respondents were not asked for infor-
ment (as faced by their parents), when immigration took mation about their immigration class at the time of entry.10
place at young age (Pores and Rumbaut 2005; as cited by Thirdly, most of these studies combined immigrant popula-
Khanlou 2009). tion with non-immigrant population in the analysis, and
4. Using the CCHS cycle 3.1, Bergeron et al. (2009) provide rich information on the factors that influence the
examined the relationship among time since immigration, overall mental health of the overall population. However,
visible minority status, and knowledge of an official it is not known whether the factors that affect non-immi-
language with self-rated health, self-rated mental health grant mental health are the same as those for immigrant
and body mass index for immigrants residing in population. There is therefore a need for studies in this
Montral, Toronto and Vancouver, Canadas largest area. Fourthly, some of the authors acknowledged that
metropolitan and gateway cities.9 Concerning mental there are limits associated with the measurement of
health, the study found that recent visible minority immi- mental health, and that self-reported mental health can be
grants were less likely to report poor mental health prone to reporting errors due to non-objectivity or
relative to the non-immigrant population. Although this cultural differences, such as variation of social accept-
study supports the healthy immigrant effect, the effect is ability of the reporting of poor mental health. Individual
only present in certain subgroups of immigrants. Specifi- interpretation and construction of what healthy means
cally, non-visible minority recent immigrants did not may also change with time spent in Canada, as well as
report better mental health than the non-immigrant with age. Lastly, while age was included to control for the
population, contrary to what the healthy immigrant effect age effect in all the studies reviewed, it is also important to
would suggest. examine age effects per se on mental health in the context
Although the study controlled for individual level of life course transitions (Khanlou 2009).
characteristics such as age, sex, education, income,
marital status and region, the results were not reported. Concluding Remarks and Future Prospects
A limitation of the study is that it did not take into consid- The health survey program at Statistics Canada has
eration intermediate or systemic levels. provided information to health practitioners, researchers
and policy makers to understand immigrant mental
Discussion health. All CCHS cycles gathered several dimensions of
The consensus from this review is that these studies mental health, and can be used by researchers to examine
in general provide support for the healthy immigrant various aspects of immigrant mental health, other than
mental health effect and its loss overtime. However, there the healthy immigrant effect. For example, Smith et al.
are some exceptions to this overall conclusion. For (2007) used CCHS 1.1 to examine the effects of income
example, Wu and Schimmele (2005) noted that the and gender on depression among immigrants and found a
Chinese ethnic group has better overall mental health differential income effect on depression for male and
than those from Northern and Western Europe. As well, female recent immigrants. Researchers have also used
Bergeron et al. (2009) also observed that the healthy other Statistics Canada surveys such as National Longitu-
immigrant mental health effect is only present in certain dinal Survey on Children and Youth to study topics such

26
 Is there a Healthy Immigrant Effect in Mental Health? Evidences from Population-Based Health Surveys in Canada

as behaviours and outcome of immigrant children (e.g. Canadian Council on Learning. 2007. Health literacy in
Beiser et al. 2002; Georgiades Boyle and Duku 2007). Canada: initial results from the International Adult Literacy
and Skills Survey 2007. Ottawa: Canadian Council on Learning.
Mental health has come out of the shadows in
Canada as evidenced by the formation of the Mental Canadian Council on Learning. 2008. Health literacy in
Health Commission of Canada in 2007. The Commission, Canada: a healthy understanding. Ottawa: Canadian Council
created by the Federal Government to focus national on Learning.
attention on mental health issues, has highlighted
Chen, J., E. Ng and R. Wilkins. 1996a. The Health of Canadas
immigrant and refugee, ethno-cultural and racialized
Immigrants in 1994-95. Health Reports, 7(4):33-45.
groups as one of the priority areas for investigation in
terms of mental health services appropriateness. One Chen, J., R. Wilkins and E. Ng. 1996b. Health Expectancy by
recent data development at Statistics Canada that Immigrant Status. Health Reports, 8(3):29-37.
attempts to link health records with Statistics Canada
Chui, T., H. Maheux. and K. Tran. 2007. Immigration in
surveys can potentially enable researchers to examine the
Canada: A Portrait of the Foreign-born Population, 2006
health care utilization patterns for groups with different Census. Catalogue no. 97-557-XIE. Ottawa: Statistics Canada.
health conditions (Canadian Institute for Health Informa-
tion 2008). For example, one can examine from the linked Georgiades K., M.H. Boyle and E. Duku. 2007. Contextual
datasets whether immigrants experienced more or less Influences on Childrens Mental Health and School Perfor-
mental health related hospitalization than the local-born mance: The moderating Effects of Family Immigrant Status.
population. Also, the 2012 Canadian Community Health Child Development, 78(5) Pp1572-1591.
Survey which has a mental health focus may also be an Khanlou, N. 2009. Immigration mental health policy brief
appropriate population-based survey for researchers to prepared at the request of the Public Health Agency of Canada
gain more recent insights on mental health issues of and Metropolis Canada, Ottawa. March 30, 2009.
immigrant and ethno-cultural groups.
Finally, health literacy, defined as the ability to access Lou, Y. and R. Beaujot. 2005. What happens to the healthy
and use health information to make appropriate health immigrant effect: the mental health of immigrants to Canada.
Discussion paper no. 05-15. London, Ontario: Population
decisions and maintain basic health (Canadian Council
Studies Centre, University of Western Ontario.
on Learning 2007), has been identified as an important
health-related tool to improve the population health McDonald, J. T. and S. Kennedy. 2004. Insights into the
(Canadian Council on Learning 2007 and 2008). However, Healthy Immigrant Effect: Health Status and Health Service
the role of health literacy on mental health has not been Use of Immigrants to Canada. Social Science and Medicine, 59,
well studied (Simich, 2009). The International Adult 1613-1627.
Literacy and Skills Survey (IALSS) is a unique survey that Newbold, K. B. and J. Danforth. 2003. Health Status and
allows researchers to examine the mental condition of Canadas Immigrant Population. Social Science and Medicine,
immigrants and refugees compared to non-immigrants, 57, 1881-1995.
as well as to understand the role of health literacy on
mental health. Ng E, R. Wilkins, F. Gendron and J.M. Berthelot. 2005.
Dynamics of Immigrants Health in Canada: Evidence from the
National Population Health Survey. In Healthy Today, Healthy
Survey (Statistics Canada, Catalogue 82-618). Ottawa: Statistics
References
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Ali, J. 2002. Mental Health of Canadas Immigrants, Health
Noh S, M. Beiser, V. Kaspar, F. Hou, J. Rummens. 1999.
Reports, 13 (Suppl.), 1-11. Ottawa: Statistics Canada.
Perceived Racial Discrimination, Depression, and Coping: A
Bergeron P., N. Auger and D. Hamel. 2009. Weight, General Study of Southeast Asian Refugees in Canada. Journal of Health
Health and Mental Health: Status of Diverse Subgroups of and Social Behaviour, 40: 193-207.
Immigrants in Canada. Canadian Journal of Public Health. Vol.
Perez, C.F. 2002. Health Status and Health Behaviour among
100(3): 215-20.
Immigrants. Health Reports, 13(Suppl.): 89-100.
Beiser, M., F. Hou, I. Hyman, and M. Tousignant. 2002.
Portes, A. and R.G. Rumbaut. 2005. Introduction: The Second
Poverty, Family Process, and the Mental Health of Immigrant
Generation and the Children of Immigrants Longitudinal
Children in Canada. American Journal of Public Health;
Study. Ethnic and Racial Studies, Vol. 28 (6), 983-999.
92:220-27.
Simich L. 2009. Health literacy and immigrant populations:
Canadian Institute for Health Information. 2008. A Framework
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for Health Outcomes Analysis: Diabetes and Depression Case
of Canada and Metropolis Canada, Ottawa. March 30, 2009.
Studies. Ottawa: CIHI.

27
 Edward Ng and D. Walter Rasugu Omariba

Simth K.L.W., F.U. Matheson, R. Moineddin, R.H.Glazier. 2007. 4

The reviews reported here are summary findings. Readers are
Gender, Income and Immigration Differences in Depression in encouraged to examine for themselves the respective articles
Canadian Urban Centres. Canadian Journal of Public Health; and reports reviewed.
98(2):149-153.
5
The CCHS 1.1 survey collected information on health status
Wilkins R, M. Tjepkema, C. Mustard, and R. Choinre. 2008. and health care utilization from over 131,000 respondents
The Canadian Census Mortality Follow-up Study, 1991 through aged 12 and over in all provinces and territories.
2001. Health Reports, 19(3). Pp. 25-43.
6
The CCHS cycle 1.2 was a survey conducted in 2002 with a
Wu Z. and C. Schimmele. 2005. The Healthy Migrant Effect on sample of 36,984 respondents.
Depression: Variation Over Time? Canadian Studies in Popu-
lation, 32(2). Pp 271-298.
7
The structural strain theory relates to the lack of sustained
economic growth following the large numbers of arrivals that
influence immigrant mental health through fewer opportuni-
ties and increased competition. The stress theory refers to the
impact of acculturative stress results from uprooting, reloca-
footnotes tion and adaptation, and the interaction between certain risk
factors such as alienation and discrimination and the strength
1
For various reasons, good health is associated with the immi- of coping factors such as psychological resources and sense of
gration process. For example, healthier people tend to be more belonging to community.
likely than those in poor health to emigrate (self-selection
effect). As well, immigration screening rules in Canada also 8
This study used the NPHS cycle 2, conducted in 1996-97, had a
ensure that mostly healthy immigrants are selected in at entry. sample of about 70,000, after excluding children under 12 for
whom no mental health condition was collected and cases
2
Many reasons have been put forth to explain this apparent loss where any dependent mental health measure was missing.
of health with the increase of time spent in Canada. For
example, immigrants may encounter stress and barriers in the 9
The CCHS cycle 3.1 was conducted in with a sample of 132,947
settlement period leading to health problems. Alternatively, respondents. This study focused on the 22,694 respondents
immigrants may adopt negative health behaviours and residing in Montreal, Toronto and Vancouver.
sedentary lifestyle that lead to gradual health decline.
10
Though not a health survey, the Longitudinal Survey of Immi-
3
Other evidences on mental health of immigrants can be found grants to Canada is a good exception, as it contains both
in Hyman (2007), which reviewed recent work on mental immigrant class information and on mental and physical
health of seniors, children and youth, women, and refugees health condition of recent immigrants (including incidence of
(adults and youth) and in Khanlou (2009), which also summa- emotional problems and stress levels).
rized finding of review of mental health of migrant
populations.

28
The Mental Health of Immigrants
and Minorities in Canada:
The Social and Economic Effects1
Mengxuan Annie Xu was born and raised in Northern China. In 2001 she came to Canada for her graduate studies. She completed
a masters degree in Economics, and a second masters in Applied Health Services Research, both at the University of New Brunswick.
After school she worked for Nova Scotia Department of Health as an epidemiologist for five years. She is currently working as an
Evaluation Officer at Human Resources and Skills Development Canada.
James Ted McDonald completed his Ph.D. in Economics at the University of Melbourne in 1996 and after 5 years at the University
of Tasmania, began his current appointment in the Department of Economics at the University of New Brunswick, Canada in 2001.
His current research focuses mainly on the relationships between socio-economic status, ethnicity and cancer.

abstract
This article provides a comprehensive analysis of immigrant mental health from a population health perspective. The result of the
research conducted by the articles authors confirms that there is a healthy immigrant effect in terms of mental health outcomes.
It also offers evidence of the significant role that local ethnic networks play in influencing immigrant mental health.

Introduction between immigrants and native-born individuals of

Resulting from centuries of immigration, Canada is a comparable socio-economic and demographic character-
multicultural nation comprised of people from a wide istics, our study contributes to the literature on
range of ethnic and cultural heritages. Immigrants have immigrant mental health in the following two ways. First,
always made and will continue to make significant contri- it provides evidence on how the observed difference varies
butions to the development of Canadas economy, society, by year of arrival in Canada, by years since migration, by
and culture. However, migration to a new country is a age at arrival, and by ethnicity. Second, it offers additional
potentially disruptive and stressful experience. It can evidence on the influence of local ethnic communities on
produce profound distress even among the best prepared. immigrants mental health. Analyses of these focal points
Difficulties in connecting with and adapting to the will yield important insights into the extent to which
economic and social institutions of the host country may immigrants acculturate into the Canadian society in
result in poor mental health outcomes. This in turn can terms of mental health, and whether the process of
hinder longer-term economic and social adjustment such acculturation is on balance a positive or negative effect.
as labor market performance, linguistic and cultural A better understanding of the dynamics and deter-
adjustment, etc. minants of mental health for potentially at risk groups is
Our understanding of the determinants of the vital both to the prosperity and success of new immi-
mental health of immigrants in Canada and how their grants to Canada and, more broadly, to the success of
mental health changes over time is limited. In previous Canadas ambitious immigration program. Results of this
research, considerable attention has been paid to the study can be used to identify these at-risk groups and the
variation in mental health among ethnic groups and the factors that contribute to their poorer mental health. This
underlying causes, but the findings have been inconsis- information in turn can be used to guide particular policy
tent. This article provides an examination of our study development that addresses those factors and improves
which aims to address some of the serious gaps in the the health, quality of life and prosperity of immigrant and
general understanding of the mental health of immigrants native-born Canadians.
and minorities in Canada by estimating statistical models
involving a range of mental health measures and socio- Methods
economic, demographic, and immigration-related factors. Following the approach of McDonald and Kennedy
By analyzing the extent of differences in mental health (2004), our study analyzes various dimensions of

29
 Mengxuan Annie Xu and James Ted McDonald

immigrant and minority mental health using micro- The CCHS is a series of national health surveys conducted
econometric techniques. The main approach is to by Statistics Canada. It contains rich information on
estimate a series of regression models in which mental health determinants, health status, and health system
health is expressed as a function of socio-economic and utilization for over 130 health regions across the country.
demographic conditions. In these models, mental health For the purpose of this study, only working age individ-
is defined by an aggregated index constructed using a uals aged 20 to 65 are included since individuals from this
number of most commonly used mental health indica- age group are likely to face similar mental health stressors
tors including stress, depression, alcoholism and suicidal such as those related to employment and family respon
ideation. A higher index score indicates a higher sibilities. The 2001 Canadian Census data file is used to
incidence of various mental health conditions. The calculate population sizes of local ethnic groups.
socio-economic and demographic factors included are
gender, age, marital status, education, home ownership Results
(as a proxy for income), social support, physical Our study compares the incidence of mental
health, and ethnicity. Controlling for observable socio- health conditions between immigrants and native-born
economic and demographic differences in the regression Canadians to examine the evidence of a healthy
allows the extent to which mental health varies between immigrant effect. The results show that, overall, immi-
immigrants and otherwise comparable non-immigrants grants enjoy a significantly better mental health than their
to be identified. Further, given the wide variation in comparable native-born peers. When comparing the
immigrant inflows by source country, by age at arrival status of mental health among various ethnicity groups, it
and by year of arrival, it is of interest to compare across is found that people who belong to Asian and Black
different immigrant groups defined by these measures minority groups are less likely to have mental health
after controlling for differences in observable character- problems than their white counterparts. Latin American
istics such as age and education level. For example, it will men are also found to have a better mental health status
be instructive to compare the mental health of recent compared to their white counterparts, but no such rela-
adult immigrants of a particular ethnicity with that of tionship is found for women.
otherwise similar native-born Canadians of the same To determine how immigrants mental health
ethnicity, or with immigrants of the same ethnicity who changes over time, this study examines the relationship
arrived as children, as well as with immigrants and between the mental health of immigrants and their length
native-born Canadians of other ethnicities. of residence in Canada. It provides strong evidence that,
Using this framework, the study examines two for both male and female immigrants, their mental health
important aspects of immigrant mental health that have deteriorates with increased years of residence in Canada.
been identified in the literature on immigrant physical Moreover, both period of arrival and age at arrival are
health. The first is the existence of a healthy immigrant important determinants of immigrants mental health.
effect in terms of mental health; that is, the extent to Immigrants who arrived during 1961 to 1965 are found to
which recent arrivals are in better mental health than have a poorer mental health than others. The implied
otherwise comparable non-immigrants. Related to this, it negative impact on mental health for those arrived within
is also of interest to determine whether any health the time frame could be a reflection of Canadas large
advantage enjoyed by recent immigrants is lost with addi- intake of immigrants and refugees during the early 1960s
tional years in Canada, as has been found to be the case for humanity reasons (The Applied History Research
for physical health. Second, the study also attempts to Group, University of Calgary, 1997).2 It is also found that
measure the relationship between an immigrants mental men who have arrived in Canada after age 50 enjoy a
health and characteristics of his or her local neighbor- significantly better mental health than those who arrived
hood, such as local ethnic concentration. This variable at an earlier age, while men who have arrived in Canada as
captures the individuals proximity to and interaction children (before age 12) have a disadvantage in mental
with people of the same language, background and health compared to those who arrived at a later age.
customs. Local ethnic concentration is measured as the Again, no such evidence is found for women.
proportion of population belonging to a particular ethnic In terms of the different findings between male and
group in the neighborhood, relative to that ethnic groups female immigrants, one possible explanation is that men
population proportion at the national level. The are more likely to be the principal applicants for immigra-
approached used in measuring this relationship follows tion while women are more likely to immigrant to Canada
Bertrand et al. (2000). as spouses. For example, between 2000 and 2001, 77% of
This study uses 2001-2005 data from the confidential the principal applicants in the economic class were men,
files of the Canadian Community Health Survey (CCHS). while immigrant women who were admitted under this

30
 The Mental Health of Immigrants and Minorities in Canada: The Social and Economic Effects

category were more likely to be admitted as a spouse or a The findings of this study contribute to our
dependent. The principal immigration applicants are the knowledge that mental health is closely related to demo-
ones who initiate the immigration process and therefore graphic and socio-economic factors. It is also found that a
are those who might be most affected by the nature of the wide range of mental health disparities exists across
immigration process. Spouses or dependents might be different ethnic groups. By examining the extent to which
more likely to experience an accommodated process, differences in mental health status are explained by immi-
particularly if there is a time lag between the arrival of the gration status, this study presents some tentative evidence
principal migrant and his or her spouse and family. on a health immigrant effect on mental healthmost
Mental health is also found to be closely related to visible minority groups enjoy a better mental health status
local ethnic and neighborhood factors. Evidence suggests than their white counterparts, however the mental health
that it is beneficial for immigrants mental health if they of immigrants deteriorates over time.
reside in a neighborhood with a higher density of individ- This study also contributes to the existing literature
uals who are from the same ethnicity. There is also a by offering additional evidence on the influence of local
positive relationship between an individuals mental ethnic networks on mental health. It reveals that local
health status and the average mental health status of the ethnic networks have significant effects on the mental
ethnic group from the same neighborhood. health of immigrants and minorities. It is found that
In terms of the relationships between mental health residing in a neighborhood with a high ethnic density is
and socio-economic, demographic factors, this study beneficial for an individuals mental health. This may be
reveals similar findings as in the existing literature. For attributed to the potential protective effects offered by a
both men and women, the incidence of mental health high ethnic density such as strong ethnic networks, acces-
conditions increases with being divorced or separated, sible and available social support, as well as sense of
living in a metro area, having poor or fair physical health, familiarity and belongingness.
etc, and decreases with receiving social support, having
very good or excellent physical health, etc. The relation-
ship between mental health and age is U-shaped over the
life cyclethat is, mental health is the best among youth References
and old age while mental health problems are the most
common among men and women in their middle age. Bertrand, M., E. Luttmer, and S. Mullainathan. 2000. Network
Effects and Welfare Cultures. The Quarterly Journal of
Persons who have post-secondary education are more
Economics, 115: 1019-1055.
likely to experience mental health conditions compared to
secondary school graduates (more so for women than for McDonald, J.T. and S. Kennedy. 2004. Insights into the healthy
men). House ownership and house type are also predic- immigrant effect: health incidence and health service use of
tors of mental health. Those who own their own houses immigrants to Canada. Social Science and Medicine, 59(8):
are estimated to have less mental health conditions than 1613-1627.
those who do not, and those who live in single houses also The Applied History Research Group, University of Calgary.
have less mental health conditions than those who live in The Peopling of Canada: 1946-1976. University of Calgary.
other accommodation types (apartment, mobile home 1997. http://www.ucalgary.ca/applied_history/tutor canada1946/
etc). As house ownership can be considered as an index.html (November 19, 2008).
indicator of ones long-term wealth, these results suggest a
positive relationship between mental health and wealth.

Conclusions footnotes
Issues related to immigrant mental health are funda-
mental to Canadas immigration policy development. 1
The opinions expressed in this article are those of the authors
First, the mental health of immigrants is an important and do not necessarily reflect the views of the Department of
determinant of general measures of population health, Human Resources and Skills Development Canada or the
and therefore is directly related to issues of the cost and Government of Canada.
adequacy of Canadas healthcare system. Second, the 2
Due to high unemployment rates in Canada and global
mental health of Canadas immigrant population is one humanitarian actions in the first years of the 1960s, Canada
important determinant of the costs and benefits of revised its immigration policy to accommodate more immi-
Canadas immigration policy, and relates to questions grants and refugees, including those who would not normally
such as whether Canada is maximizing the returns of its have qualified for admission (The Applied History Research
large-scale immigration program. Group, University of Calgary, 1997).

31
32
A Review of the International
Literature on Refugee
Mental Health Practices
Biljana Vasilevska is the research coordinator of the Refugee Mental Health Practices study.
Laura Simich is the principal investigator of the Refugee Mental Health Practices study.

abstract
This article is a summary of the literature review for the Refugee Mental Health Practices study. The goal of the study is to fill the gap
in empirical research on services that are available for refugees to Canada which supports their mental health, emotional wellbeing,
resiliency and recovery. The review is organized according to themes relating to three levels: the individual (refugees); the level of social
systems (medical care and service provision), and policy-level decision-making.

Acknowledgements:
The Refugee Mental Health Practices study was funded by Citizenship and Immigration Canada.

Since 2000, Canada has supported the resettlement Refugee-Level Themes

of approximately 7,500 refugees annually. With the
introduction of the Immigrant and Refugee Protection Explanatory Models
Act, IRPA, in 2002, the criteria for eligibility for govern- Recent work has sought to understand how refugees
ment-assisted resettlement softened to give greater and other ethno-minority groups conceptualize and
consideration of refugees needs. With less emphasis express emotional distress and how these cultural
being placed on their ability to integrate quickly, many conceptions may differ from the Western medical
refugees now have different settlement needs that perspective or vocabulary. Studies have sought to under-
include special requirements arising from years of stand the gaps between clients and mental health services,
trauma or torture followed by years in camps (Press & and how differences may be bridged. Arthur Kleinmans
Thomson, 2007). concept of explanatory models [EMs] is heavily invoked in
The mental health of refugees has received more this literature. Explanatory models are the notions about
attention in the academic literature than have studies of an episode of sickness and its treatment that are employed
refugee economic integration, social identity or adapta- by all those engaged in the clinical process. The study of
tion (Ryan, Dooley, & Benson, 2008). While there is the interaction between practitioner EMs and patient EMs
some existing data on the mental health concerns and offers a more precise analysis of problems in clinical
needs of refugees, there is a greater gap in empirical communication (Kleinman, 1980). Mental health profes-
research on mental health services for refugees in sionals who work with refugee clients must be aware of
Canada (Yu, Ouellet, & Warmington, 2007). This article differences in explanatory models, that is, notions of
is a brief summary of a literature review from the cause, course and treatment for mental distress.
Refugee Mental Health Practices study, a project which
seeks to fill this gap in empirical research i. The review is Conceptual Models of Health and Care
organized according to themes relating to three levels: The Western or biomedical model of health care is
the individual (refugees); the level of social systems understood to be one where the client, as an individual,
(medical care and service provision), and policy-level seeks professional care. The professional may have no other
decision-making. relationship with the client than that of diagnosis and
treatment, and the relationship is unidirectional: the patient
changes, while the medical practitioner goes about her or

33
 Biljana Vasilevska and Laura Simich

his work. It is important to bear in mind that the biomed- Disorder (PTSD) and other mental illnesses. Meta
ical explanation of health and illness, which is common to analyses of research findings on the extent of trauma and
Canadian and many other medical professionals in the emotional distress and associated social factors in specific
Western tradition, is itself an explanatory model, one which refugee populations is presented in Table 1.
may not be comprehensible to all clients, particularly Concern has been expressed about the lack of cultur-
refugees who are also ethno-cultural minorities (Scheppers, ally sensitive diagnostic tools used in academic studies
van Dongen, Dekker, Geertzen, & Dekker, 2006). (Keyes, 2000). Moreover, the application of the concept of
In many traditional cultures, the model of care PTSD to refugees and other marginalized communities
emphasizes the connection of self and ones community, has been challenged for pathologizing individual
with a preference for social forms of intervention when responses to events which often have a social and political
mental health support is needed. The interconnectedness origin (Bracken, Giller, & Summerfield, 1995; Burstow,
of self and society is taken to be axiomatic; therefore, 2005; Friedman & Jaranson, 1994).
responsibility for care of the individual rests with the While medical care for acute mental disorders should
family or community. Psycho-social or social-ecological be available upon resettlement, refugees psycho-social
models of health care are conceptual frameworks for needs must also be addressed. As Porter and Haslam (2005)
understanding the health of individuals within society suggest, humanitarian efforts to improve the post-migration
and include social determinants of mental health, such as social and material experiences of refugees would likely have
income, social support, employment, housing, and a positive influence on mental health outcomes.
education (Public Health Agency of Canada, 2005; World
Health Organisation, 2001). Social Support
Among Southeast Asian refugees, the most Support networks are known to protect refugee
important factors contributing to positive mental health mental health, and resettled refugees in Canada may
in the post-migration period were being in a stable, signif- engage in seemingly counter-intuitive secondary migration
icant personal relationship, and having stable employment in order to be nearer to family and their own ethno-
(Beiser, 1999). Having ethnic or ethnic-like community cultural community (Simich, 2003; Simich, Beiser, &
supported mental wellbeing initially, but was not Mawani, 2003). Qualitative data show that the affirmation
necessarily supportive in the long term. An interactional of shared experiences through community-level support is
model is put forth to explain the more complex relation- a strong determinant of refugee wellbeing (Beiser, Simich,
ships between an individual and social resources that & Pandalangat, 2003; Simich et al., 2003). These findings
contribute to mental health (Beiser, 1999). corroborate epidemiological data showing that post-migra-
tion conditions matter to refugee mental health (Fazel et
Trauma Discourse al., 2005; Porter & Haslam, 2005).
Many refugee mental health studies have sought to Refugee or ethno-cultural communities may not
determine the prevalence of Post Traumatic Stress have the capacity to address acute mental illnesses

Table 1: Results of Meta-Analyses

Reference Total Articles Total Refugees Key Findings and Conclusions
Mental Health Status in Refugees: An n = 12 n =2,065 At least one negative mental health state present in
Integrative Review of Current Research populations studied
(Keyes, 2000) Only one-third of studies used culturally sensitive measurement
instruments
Psychological concerns and physical complaints present in all
the studies that used culturally sensitive diagnostic tools
Predisplacement and Postdisplacement n= 56 n = 22,221 Post-migration economic, social and housing conditions influenced
Factors Associated With Mental refugees and mental health.
Health of Refugees and Internally 45,073 non Worse outcomes experienced by refugees living in institutional
Displaced Persons: A Meta-analysis refugees accommodation and experiencing restricted economic opportunity.
(Porter & Haslam, 2005) Refugees who were older, more educated, female, had higher
pre-displacement socioeconomic status and rural residence also
had worse outcomes.
Prevalence of serious mental disorder n=20 n= 6,743 9% to 11% of refugees resettled in Western countries were
in 7000 refugees resettled in western diagnosed with post-traumatic stress disorder (PTSD).
countries: a systematic review (Fazel, 4 % of resettled refugees experienced a generalized anxiety
Wheeler, & Danesh, 2005) disorder, and about 5% suffered from major depression.

34
 A Review of the International Literature on Refugee Mental Health Practices

without the help of medical professionals, yet they may be program being piloted, and broad approaches or schools
well-equipped to support mental wellbeing and prevent of thought which influence service provision. Ingleby
emotional distress. Programs in Canada (Li, Koch, & and Watters (2005) use the following groupings: main-
Angelow, 2008) and in the United States (Weine et al., stream health care approaches; multicultural health
2003) have sought to formally encourage social support care approaches; sociological health care approaches;
through multi-family group-therapy types of programs. managed care, and service provision which has been
Some agencies match clients with volunteers in a influenced by the users movement.
befriending program or foster mutual supports groups Currently in Canada, there is a focus on client-
with a goal of breaking down isolation (Canadian Centre centred care, which should include refugees and
for Victims of Torture, 2009). Many formal programs are ethno-cultural minorities. Ryan, Dooley and Benson
offered through settlement and social service agencies, (Ryan et al., 2008) advocate a resource-based model, in
which do not often have the capacity to engage in evalua- which resources are personal, material or social. Services
tion and reporting of their activities. Therefore there is a premised on such a model would acknowledge that
need for more empirical research. refugees are not passive victims of trauma; they are active
survivors in a new environment which affects their
mental health and adaptation as well (Birman et al., 2008;
Systems-Level Themes Birman & Tran, 2008) Services that capitalize on refugees
Program Accessibility and Barriers resources should be considered in future policy and
Refugees face many barriers to accessing mental health programming decisions.
services, both in Canada and internationally. In Canada, the
challenge is in part due to the difficultly of finding culturally Bridging Primary Care and Mental Health
appropriate care and the lack of interpretation services in The importance of bridging primary care and mental
the health care system in general (Gagnon, 2002; Scheppers health systems is underscored often by the World Health
et al., 2006; White, 2008). Similar under-usage of health Organization (World Health Organisation and World
services has been found by ethnic minorities in other indus- Organization of Family Doctors (Wonca), 2008; World
trialized Western nations (Chow, Jaffee, & Snowden, 2003; Health Organization, 2009). Upon arrival in Canada,
Guerin, Abdi, & Geurin, 2003; Scheppers et al., 2006; Ten refugees primary health care needs often have not been
Have & Bijl, 1999). While mental health service providers in met for many years, and it is through primary care that
Canada are working to eliminate systems level barriers, most refugees experience their first contact with the
perceptions of barriers may persist. Perceived accessibility of Canadian medical system. Mental health concerns are
a service influences attitudes towards seeking help. If the often raised in primary care settings, in the context of
perception of access to mental health services is improved dealing with physical problems. Headaches, fatigue, diffi-
through outreach programs, then more refugees and ethno- culty sleeping, and difficulty breathing are physical
cultural minorities may be encouraged to use services (Fung complaints that may be expressions of psychological
& Wong, 2007). disturbances (Patel, 2002; Summerfield, 2005).
Ingleby (2009) puts forth three components to To increase capacity in primary care settings to
accessing services: entitlement to care (a question of better work with clients from diverse cultures, holistic,
legality and status), ease of accessibility, and the level of anthropological perspectives may aid in medical training
trust one has in a service and expectation of positive and practice (Gozdziak, 2004; Kleinman, 1980). Some
results (Ingleby, 2009). Scheppers and colleagues catego- practitioners have promoted the need for recognizing the
rize barriers to services according to a three-level model roles of spirituality (Collins, 2008; Mollica, Cui, McInnes,
of interaction: patient level, provider level, and system & Massagli, 2002) and the family (Stepakoff et al., 2006) in
level (Scheppers et al., 2006). While differently directed, refugee mental health care. Given the barriers refugees
both models emphasize a dynamic and systemic under- and ethno-cultural minority groups face when accessing
standing of access and barrier, rather than focusing on the mental health services, some initiatives have sought to
individual in need of care. bridge services from multiple sectors, including mental
health and social services, and to foster informal,
Models of Service Delivery community supports. Success has been demonstrated in
A number of approaches and models of service programs that bridge gaps among services and build the
delivery have been described. These include inductive internal capacity of agencies to better work with cultural
models based on the qualitative input of clients and minority clients (Kirmayer, Groleau, Guzder, Blake, &
service providers, a model of a specific service or Jarvis, 2003; Yeung et al., 2004).

35
 Biljana Vasilevska and Laura Simich

Policy-Level Themes Conclusion

Current resettlement programs do not meet the
Lack of Policy mental health and wellbeing needs of Canadas
The World Health Organizations 2001 Annual newcomers, in particular refugees. Displaced people who
Report, Mental Health: New Understanding, New Hope, have sought refuge in Canada face real challenges in
states that most countries do not have a national mental obtaining culturally appropriate services for mental
health policy. This statement applies to Canada, with health problems that may not be understood well by
different levels and breadth of service coverage across the medical practitioners. Given Canadas humanitarian
country, compounded by a lack of policy to address the commitment to refugee resettlement and the more acute
needs of low English/French proficiency clients (Abraham needs of todays refugees, there is a need for culturally
& Rahman, 2008). There has been movement towards inclusive and appropriate mental health care practices for
filling this gap in recent years. The consultation activities refugees. In particular, practices should be based on
of the new Mental Health Commission of Canada and models which are more likely to be understood and
publication of a discussion paper on Ontarios mental accepted by clients from diverse cultural backgrounds,
health care strategy (Ontario Ministry of Health and Long and which do not take the individual as the sole unit of
Term Care, 2009) are examples. care, but which included the family, the community, or
While mental health is a concern for all Canadians, the broader population. At the program or service level,
refugees are especially vulnerable. They have experienced more culturally competent care is needed. Programs may
significant pre-migration stress and likely need services have no obvious institutional barriers, but because there
immediately upon entering Canada, yet they cannot be has been little outreach to refugee and ethnic minority
expected to know how to access those services. However, communities, the perception of accessibility needs to
it is the post-migration conditions that potentially improve, as well as the quality of care. While some mental
have the greatest moderating effect on refugee mental health service and settlement service providers are
health and which the Canadian policy environment is most working to provide more comprehensive care at the local
able to address. Current pre-settlement health screening level, the lack of integration of sectors and services is most
practices in refugee camps are narrowly focused, and leave appropriately addressed at the provincial and national
insufficient opportunity for mental health promotion and policy or systems level.
prevention (Gushulak & Williams, 2004).

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2001: Mental Health: New Understanding, New Hope. footnotes

World Health Organisation and World Organization of Family

1
The full review will be available with the final report, in spring
Doctors (Wonca). (2008). Integrating mental health into primary of 2010.

38
Compassionate Admission and
Self-Defeating Neglect: The Mental
Health of Refugees in Canada
Morton Beiser is Professor of Distinction and Program Director Culture, Immigration and Mental Health, Dept of Psychology, Ryerson
University; Crombie Professor Emeritus of Cultural Pluralism and Health, University of Toronto; and Founding Director and Senior
Scientist, Ontario Metropolis Centre of Excellence for Research on Immigration and Settlement (CERIS). Past academic appointments
include Associate Professor of Behavioral Sciences, Harvard School of Public Health (1965-1975); Professor and Head, Division of
Cultural Psychiatry, Department of Psychiatry University of British Columbia (1975-1991), David Crombie Professor of Cultural Pluralism
and Health, and Head, Culture, Community and Health Studies, University of Toronto (1975-2002).

abstract
The Ryerson University Refugee Resettlement Project, a decade-long investigation of the admission and resettlement of 1348 Southeast
Asian Boat People, is the largest and longest-lived investigation of refugee resettlement and mental health ever attempted. Findings
are summarized in the form of four propositions: i) considerations of refugee mental health must take into account not only vulnerabili-
ties but also resilience and its sources ii) resettlement is a long, perhaps even a life-long process iii) men and women experience
resettlement differently and iv) mental health is human capital. Each of these propositions is illustrated by research findings.

Acknowledgements:
The research on which this article is based was made possible by grants from the National Health Research Directorate Program
(NHRSDP), Health Canada, to Dr. Morton Beiser (Principal Investigator), Dr. Phylis Johnson and Dr. Richard Nann (co-PIs).
Canada is one of 147 countries who have signed singular and important event in Canadian immigration
the UN Convention on refugees, pledging to provide history. Prior to 1979, Canadas response to asylum
asylum for the persecuted and the stateless. Canada is also seekers had ranged from tight-fisted to shameful. In a
one of a much smaller group of Convention signatories dramatic about-face, this country responded to the
about 20who offer not just temporary protection, but Southeast Asian refugee crisis by admitting more people
the option of permanent resettlement. Although on a per capita basis than any other country. In the years
protecting the oppressed is consistent with our national since, Canada has become a world leader in refugee
values, critics question the wisdom of this countrys rela- and immigrant affairs, and the citizens of Canada have
tively generous refugee policies. They ask how much it gained an enviable reputation as people who care.
costs to admit and resettle refugees, and whether the The history of the Boat People crisis begins with the
demand for mental health and social services is a drain on fall of Saigon in 1975, an event that precipitated a
the countrys resources. large-scale exodus from Southeast Asia. Shortly after
The Ryerson University Refugee Resettlement their victory over the combined forces of the US and the
Project, a decade-long investigation of the admission and South Vietnamese military, the new North Vietnamese
resettlement of 1348 Southeast Asian Boat People, communist government sealed the countrys borders. A
provides some answers. It also points to ways in which few years later, angered by Chinas incursions along its
policy and practice could be improved in order to better northern border, Hanoi expelled all ethnic Chinese living
safeguard the mental health and human capital of in Vietnam. Ethnic Vietnamese, unhappy about living
refugees coming to Canada. under the communist regime, took advantage of the
confusion surrounding the massive expulsions to escape
The Refugee Resettlement Project along with the Chinese. At roughly the same time,
The admission of a large complement of Southeast Vietnam began conducting raids on neighbouring
Asian Boat People between 1979 and 1981 was a Southeast Asian countries. The ensuing instability created

39
 Morton Beiser

an opportunity for Cambodians to escape the tyranny of that promote resilience is at least as important as identi-
Pol Pot, and for Laotians who feared retaliation because of fying pre- and post-migration miseries.
previous alliances with the west to flee their homeland. According to the RRP results, the availability of a
Canadas 1976 Immigration Act contained a provision like-ethnic community is one of the most powerful
for private sponsorship of refugees. To encourage individ- forces promoting resilience, at least in the short and
uals as well as organizations such as church groups to medium term. In 1981, when the refugees arrived in
become private sponsors, the government of the day Vancouver, that city could boast one of the largest
pledged to match every refugee admitted under private Chinese communities anywhere in North America.
auspices with another to be sponsored by government. The There were, however, no Vietnamese, Laotian or
final tally of refugee admissions between 1979 and 1981 Cambodian communities in place. In 1981, the rate of
was 60,000, among whom 5,000 were resettled in and depression among non-Chinese refugees was three times
around Vancouver, British Columbia. With funding from higher than it was for the Chinese. The mental health
Canadas National Health Research and Development advantage did not last long. By 1983, non-Chinese rates
Program (NHRDP) in 1981, two University of British of depression dropped to the point where they equalled
Columbia (UBC) colleagues, Dr. Phyllis Johnson and Dr. Chinese rates. During that time, the non-Chinese were
Richard Nann, and I initiated the Refugee Resettlement establishing their own ethnic-based communities
Project (RRP). We conducted an initial mental health thereby linking an uncertain present to the past, and
survey on a community sample of 1348 adult refugees in affirming the worthiness of their shared history and
1981, and two follow-up surveys, the first in 1983, the last culture within the largely uncomprehending European-
in 1991. When I left UBC in 1991, the administrative base dominated Canadian society of that era.
for the project shifted to the University of Toronto, and Newcomers do not always have ready-made like-
from there to Ryerson, the first university in Canada to ethnic communities waiting for them. Someone has to be
declare a major focus on immigration studies. RRP the first to arrive. Canadas decision to admit the
products include one book (Strangers at the Gate, Univer- Southeast Asian refugees under either private or govern-
sity of Toronto Press, 1999) and approximately 50 scientific ment sponsorship created an experiment in nature that
publications. This article recaps some important lessons the RRP investigators used to test the idea that private
learned from the study in the form of propositions: i) there sponsors might potentially provide the support refugees
is a need to shift from a single-minded focus on risk factors typically look for in like-ethnic communities.
that jeopardize mental health to a broader framework that Like all citizens and permanent residents of Canada,
includes not only risk, but an understanding of resilience the refugees were entitled to provincially administered
and its determinant, ii) resettlement is a long, perhaps even insured health care. Many received language training in
a life-long process; iii) men and women experience reset- federally funded programs, and their children attended
tlement differently; and iv) mental health is human capital. schools supported by provincial tax dollars. Privately
Proposition 1: Challenge and Resilience: By defini- sponsored refugees got a little extra. Sponsors were
tion, refugees have suffered trauma and persecution, obliged to provide financial support for the person or
experiences that jeopardize mental health. On top of that, family they sponsored for a period of one year, or until the
coming to Canada entails challengescultural disrup- person or family had achieved financial stability,
tion, separation from family and community, and the whichever came first. Moved by the horrors of the
need to learn a new language and new ways of doing Southeast Asian experience, most private sponsors did
thingsall of which threaten well-being. Since all much more: they helped refugees find jobs, schools for
refugees suffer these psychological assaults, the rate of their children, doctors and dentists.
mental disorder among refugees could potentially be very Assuming that the level of welcome the privately
high. However, most refugees never become mental health sponsored group received would give them an advantage
casualties. Despite all the pre- and post-migration chal- over the government sponsored whose only official guide to
lenges they face, most refugees manage to attain some the new society was a usually overworked civil servant, we
degree of inner peace, to work, and to find a way to predicted that privately sponsored refugees would enjoy
integrate into Canadian society. In other words, risk does better mental health than the government sponsored
not necessarily translate into damaged mental health. refugee. In the short run, the prediction proved wrong.
Human resilience helps convert risk into challenges, most There were no mental health differences between the two
of which refugees apparently manage to overcome. groups in 1981 or in 1983. In retrospect, government and
Finding ways to support the personal and social resources academics were more impressed with the virtues of private

40
 Compassionate Admission and Self-Defeating Neglect: The Mental Health of Refugees in Canada

sponsorship than the refugees themselves. Half of all 8 per cent still spoke no English. It is troubling that, as
privately sponsored Southeast Asian refugees and almost long as a decade after arriving in Canada, a small, but
all the government sponsored refugees said that govern- significant number of newcomers had not acquired one of
ment sponsorship was preferable. One reason was that the most basic tools for integration.
private sponsors sometimes confused kindliness with During the initial period of resettlement, English-
intrusiveness, calling the refugees at all hours and insisting speaking ability had no effect on depression or on
on taking them to various activities. They forgot that employment. By the end of the first decade in Canada,
refugee families, like all other families, need and value however, English language fluency was a significant
privacy. Sponsors were sometimes insensitive to the predictor of depression and employment, particularly
refugees needs. For example, they often found housing that among refugee women and among people who did not
the refugees could no longer afford after the sponsorship become engaged in the labor market during the earliest
period terminated. Inequality was another source of years of resettlement.
discontent. Government sponsored refugees all got the Young, well educated male refugees were the most
same treatment, whereas, in the words of one refugee, likely to learn English during the first year or two in
With private sponsorship, sometimes it depended on luck Canada. In comparison with their young male counter-
whether you met a nice group or not. parts, females and elderly refugees tended to be less well
A sub-group of privately sponsored refugees in the educated and less likely to have had any prior exposure to
RRP was, in fact, at greater risk for depression than the English, and their level of language fluency was corre-
government sponsored. These were refugees whose spondingly lower. The initial linguistic disadvantages of
religions did not match their sponsors. Most of the women and the elderly were compounded by lack of
sponsors were Christian or non-denominational, most of opportunity. For example, because English as a Second
the refugees were either Christian, Buddhist or members Language (ESL) classes were primarily directed to persons
of one of the smaller Southeast Asian religious groups. deemed likely to enter the labour force, women and the
Non-Christian refugees sponsored by Christian groups elderly were less likely to receive such instruction. More
developed very high rates of depression. recent developments such as Canadas Language Instruc-
Although some overt attempts to proselytize the tion for Newcomers to Canada programmes have been
refugees probably contributed to the burden of depression adapted in order to reach previously neglected groups,
among the religiously-mismatched privately sponsored but women are still underserviced. Lack of language
refugees, other, more wide-spread psychological pressures compromises employability and access to services; it also
operated at a more subtle level. The refugees had difficulty limits options to participate in other important domains
understanding the concept of voluntary sponsorship. Since such as civic life and mainstream entertainment. It is
the sponsors were not family, but strangers, many refugees particularly troubling that precisely those persons most
reasoned that something was required in return. Virtually likely to be isolated by circumstancewomen, the poorly
all the sponsoring groups had been organized through a educated and the elderlyare those least likely to learn
network of multi-faith religious institutions. Since religious English, and thus to risk further isolation.
institutions provided the context for sponsorship, the According to evaluation reports from Citizenship
refugees came to believe that they were expected to adopt and Immigration Canada (CIC) (2004), most new
their sponsors religions. Some did and regretted it. Others immigrants participate in ESL training (or other second-
did not, but felt they were being ungrateful. Both circum- language training). However, the average length of
stances increased the risk of depression. exposure is less than six months, and most people attend
Proposition 2: Resettlement is a long, perhaps even a as part-time students during that period. Research from
life-long process. Factors that jeopardize or protect mental other countries demonstrates that the longer the period of
health early on can recede in importance over time, to be language training, the greater the linguistic benefit.
replaced by others that are more important for the later Immigrant ESL students in Canada have complained that
stages of resettlement. teaching methods and materials are often inappropriate,
Without language one can never really enter a new that classes are too large, and that instruction is compro-
society. Two years after their arrival in Vancouver, 17 per mised by an inappropriate mix of students with differing
cent of the refugees in the RRP sample spoke English well, levels of English ability. Addressing these problems should
67 per cent had moderate command of the language, and have an impact on both mental health and integration.
16 per cent spoke no English. Ten years later, 32 per cent Sponsorship offers an example of the way in which
had good language skills, 60 per cent moderate skills, and time affects mental health salience. As already pointed

41
 Morton Beiser

out, privately sponsored refugees had no material or stressors. With the passage of time and the resolution of
mental health advantages over their government- initial resettlement stresses, depression rates for men
sponsored counterparts during the early years of declined. Perhaps, as the risk factors for depression
resettlement. By the time 10 years had passed, that gradually lessened, predisposition began to play a stronger
changed. In 1991, the refugees who had been admitted role in predicting future depression. In other words, men
under private sponsorship were more likely than their with a constitutional predisposition tended to stay
government-sponsored counterparts to be employed, to depressed, whereas others improved when external
be speaking English and to have made friends outside pressures began to recede.
their like-ethnic community. These RRP findings are The opposite may have happened among women.
consistent with an evaluation report from CIC (2007) Predisposition may have played a strong role in accounting
which found that privately sponsored refugees entered the for the relatively strong relationship between depression
labour force more quickly than government sponsored, levels in 1981 and 1983, periods when, compared to their
and enjoyed better incomes. The CIC report also pointed male counterparts, the female refugees were relatively
out that the number of applications by potential sponsors protected from acculturative stresses. However, the longer
consistently exceeded the numbers of refugees admitted they remained in Canada, the more likely refugee women
to the country each year. were to be exposed to the structural inequities and inequal-
Canadas private sponsorship program could support ities in North American society that help account for
the countrys humanitarian goals by making it possible to elevated rates of depression among women in general. The
admit more refugees. Suggested improvements to help increasing importance of external factors in the genesis of
prevent the development of mental health risks and to depression may have diluted the role of predisposition,
promote integration include the provision of expert thereby reducing the strength of association between the
back-up for sponsors to help the latter effect an appro- 1983 and 1991 levels of depression.
priate balance between helping and respecting the need Proposition 4: Mental health is human capital.
for privacy and dignity, and to promote awareness of how Paying attention to mental health needs during resettle-
vulnerable refugees are to outside influence, well-inten- ment will promote integration and could have long-term
tioned or not. economic benefits for Canada.
Proposition 3: Gender makes a difference. At the time of the final RRP survey in 1991, Greater
In 1981, shortly after the refugees arrived, men had Vancouvers former Boat People were more likely than
higher rates of depression than women. This finding runs their native-born counterparts to be working. For people
counter to almost every other community study of depres- between 25 and 44, the age of most of the refugees, the
sion in the literature. During the years thereafter, national unemployment rate was 9.6 percent and, in
male rates of depression dropped more rapidly than female Vancouver, it was 9.1 percent. In comparison, the unem-
rates. By the end of the first decade of resettlement, sex ployment rate for the refugees was 8 percent. The refugees
ratios for depression among the Southeast Asian refugees were making a disproportionate contribution to the
resembled those in most community studies. economy. At the same time, they were taking less out of it
There is, and probably always will be, disagreement than their fellow Canadians. (Most refugees visited a
concerning the relative importance of nature versus doctor two to three times per year, just about the national
nurture in the genesis of depression. The RRP gender average, and, compared to their majority culture counter-
analyses introduced an intriguing commentary on the parts, they were less likely to use social assistance.)
debate. Among women, depression scores in 1981 Although many of the refugees in the RRP eventually
predicted depression scores in 1983 more strongly than achieved economic success, it came neither quickly nor
the 1983 scores predicted depression levels in 1991. The easily. Studies by economists such as Don deVoretz and
reverse was true for men. Persistent or recurrent depres- Jeffrey Reitz have shown that it takes seven to ten years for
sion suggests genetic or physiological predisposition, newcomersimmigrants and refugees aliketo achieve
whereas depression which disappears over time is more economic stability. In the interim, unemployment rates
likely to be associated with external factors. Shortly after are apt to be high, and incomes to be low. About one third
the refugees arrived, men were more likely than women to of all immigrant and refugee families in Canada live in
be subjected to acculturative stress because they were officially defined poverty during the first ten years of
more likely to be in the labour force. Men tended to be resettlement. Recent trends are even more troubling.
charged with the burden not only of providing for family Compared with refugees who came to Canada in the early
who accompanied them to Canada, but for those 1980s, more recent arrivals are at even greater risk of
remaining at home or in refugee camps abroad. During living in poverty during the initial years of resettlement.
this same period, women were more sheltered from When they do find employment, visible minority immi-

42
 Compassionate Admission and Self-Defeating Neglect: The Mental Health of Refugees in Canada

grants (the majority of todays immigrants and refugees) with safeguarding human rights. This is a serious issue.
earn less than their native-born counterparts, even when There is, however, little if any debate about the equally
working at the same jobs. serious issue of the role of the like-ethnic community in
Many community-based studies have shown that safeguarding mental health, or about the feasibility of
job loss is associated with a high risk for depression. creating communities of welcome that are not necessarily
Because the RRP was longitudinal, we were able to ethnically based, but that might help provide the mental
examine sequencingin other words, does unemploy- health support new settlers want and need.
ment precede, and possibly cause depression, or are Personal Reflections: National policy has been too
depressed people more likely than the non-depressed to exclusively preoccupied with adjudicating the legitimacy
lose their jobs? Both proved to be correctunemployment of refugee claims, and with developing selection proce-
is followed by depression, but depression also raises the dures to ensure that Canada admits healthy people. Too
risk of losing a job. One implication is that mental health little policy and practice are directed to ensuring that
should be added to education, training, and ability to refugees stay healthy. This neglect is wrong-headed:
speak English or French, the attributes that come to mind ensuring that new settlers not only are healthy when they
more usually in discussions about human capital. get here, but that they stay that way is just, humane, and
Although mental health should be of concern to consistent with achieving long-term national benefit.
policy makers, it rarely is. More attention needs to be paid
to both the stresses of resettlement that create risk and to
the determinants of resilience.
Unemployment has already been discussed as a risk References
factor. Discrimination is another important force. One in
five of the refugees reported experiences with discrimina- Books:
tion in the year prior to each of our surveys. Discrimi- Beiser, M. Strangers At the Gate: The Boat Peoples first ten
nation was associated with a high risk for depression. years in Canada. Toronto: University of Toronto Press, 1999.
Once again, the RRPs longitudinal design made it
possible to address a question that has plagued research. Book Chapters:
Does the experience of discrimination tend to make DeVoretz D, Beiser M, Pivenko S, The Economic Experiences of
people depressed, or are depressed people more likely to Refugees in Canada, in Peter Waxman and Val Colic-Peisker
perceive discrimination in situations that other people (eds.), Homeland wanted: Interdisciplinary perspectives on the
would likely disregard? The data show that the first propo- refugee resettlement in the West. New York: Nova Science
sition is true, the second is not. People who reported an Publishers, 2005, 1-21.
experience with discrimination were more likely to be
Beiser M. Resettlement, in Parrillo, Vincent N (ed) Encyclo-
depressed on a subsequent interview than people who had
pedia of Social Problems, Thousand Oaks, Sage Publications,
not experienced discrimination, but people who were 2008.
depressed at a particular point in time were no more likely
than anyone else to subsequently perceive discrimination. Refereed Journal Articles:
Turning to the resilience side of the equation, it is
Beiser, M. and Hou, F. Gender Differences in Language Acqui-
important to acknowledge the important role of personal
sition by Southeast Asian Refugees. Canadian Social Policy.
factors, such as linguistic fluency. The ability to speak 2000, 26 (3):311-330.
English or French is another of those variables that affects
both mental health and integration. Beiser, M., and Hou, F Language Acquisition, unemployment
Regionalizing is an example of a situation in which and depressive disorder among Southeast Asian Refugees: a
resettlement policy would benefit from considering 10-year study Social Science & Medicine 2001, 53:1321-1334.
mental health. In accordance with the policy of regional- Beiser M, Johnson P, Sponsorship and Resettlement Success,
ization, government-sponsored refugees are spread across Journal of International Migration and Integration, 2003, 4, 2,
the country, preferably to small towns and rural areas. 203-216.
However, within the first year after coming to Canada, 50
percent of government-sponsored refugees leave, and Beiser M., Resettling Refugees and Safeguarding Their Mental
migrate elsewhere in Canada, mostly to southern Ontario. Health: Lessons Learned from the Refugee Resettlement
Refugees do not identify jobs as the number one reason Project, Transcultural Psychiatry, 2009 (in press).
for their behaviour, but instead, the wish to be close to a
like-ethnic community. Debate about regionalization
tends to focus on whether or not the policy is consistent

43
 Morton Beiser

Hou F, Beiser M, Learning the Language of a New Country: A

Ten-Year Study of English Acquisition by Southeast Asian
Refugees in Canada, International Migration Volume: 44, Issue:
1, March 2006, pp. 135-165.

Simich, L. Beiser, M. and Mawani, F., Issues and Commentaries,

Paved with good Intentions: Canadas Refugee Destining Policy
and Paths of Secondary Migration, Canadian Public Policy,
2002, 28, (4): 597-607.

Simich L, Beiser M, Mawani FN. Social Support and the Signif-

icance of Shared Experience in Refugee Migration and
Settlement, Western Journal of Nursing Research, 2003, 25, 7,
872-891.

Reports:

Citizenship and Immigration Canada Evaluation of the

Language Instruction for Newcomers to Canada (LINC)
Program. 2004, ww.cic.gc.ca/english/resources/evaluation/linc/
findings.asp.

Citizenship and Immigration Canada: Summative evaluation of

Canadas Refugee Sponsorship Program. 2007, cic.gc.ca

44
Pre-Migration and Post-migration
Determinants of Mental Health for
Newly Arrived Refugees in Toronto
Ruth Marie Wilson, MSW, is a graduate of the University of Toronto. In her current role as research coordinator at Access Alliance
Multicultural Health and Community Services, Ruth coordinates two qualitative, community-based research projects looking at
racialized health disparities, particularly the relationship between income security, race and health in the lives of racialized families
living in low-income neighborhoods.
Rabea Murtaza coordinates the Determinants of Newcomer Mental Health research agenda at Access Alliance. She is a feminist,
anti-racist and queer-positive community worker, researcher, writer and facilitator. She studied Social and Political Thought at York,
focusing on situated, relational, praxis-based feminist pedagogies and epistemologies, and Physics and Political Science with a minor
in Globalization Studies at McMaster University.
Yogendra B. Shakya is the Director of Research at Access Alliance Multicultural Health and Community Services. His research
interests include social determinants of newcomer health, racialized health disparities, and globalization and community based
research.

abstract
Drawing on two community-based research projects, this article discusses pre-migration and post-migration determinants of mental
health for newly arrived refugees in Toronto. The article examines the argument that settlement policies and services need to be more
reflective of the unique challenges and needs faced by refugee groups.

Introduction the world, Canada has granted protection to over

There is small but growing body of Canadian litera- 700,000 refugees since World War II. In 1976, the
ture on refugee mental health. To add to this evidence, Canadian Immigration Act formally distinguished
Access Alliance Multicultural Health and Community between refugees and immigrants. The Act laid out both a
Services (Access Alliance) conducted two community- claim determination system for refugees landing in
based research (CBR) projects focused on newly arrived Canada as well as introducing a humanitarian category
refugee communities in Toronto from Afghan, Karen and for government sponsored refugee resettlement. The
Sudanese backgrounds. Both projects investigated deter- introduction of the Immigration and Refugee Protection
minants of refugee mental health with one project Act (IRPA) in June 2002 consolidated the commitment for
focusing on adult refugees (specifically Government Canada to proactively sponsor refugees primarily on
Assisted Refugees) and the other one on refugee youth humanitarian grounds and protection needs. This Act not
between the ages of 16 to 24.1 Drawing on these two CBR only removed additional restrictions on admissibility
projects, this article discusses pre-migration and post- based on medical or economic criteria for refugees but
migration determinants of mental health for newly also strengthened the basis for resettling refugees who are
arrived refugees. Findings from the two studies suggest particularly at high risk.
that newly arrived refugees face unique and acute forms Since 1999, Canada has been welcoming between
of pre-migration and post-migration stressors to their 25,000 to 35,000 refugees every year; this represents
mental health. about 10-12% of the roughly 250,000 permanent residents
(immigrants and refugees) that settle in Canada annually
Refugees Resettlement Trend in Canada (CIC 2008). Refugee resettlement trend in Canada
Once recognized as a world leader in global peace since 1999 is presented in Figure 1. On average, about
keeping efforts, humanitarian work, and for providing 11,000 refugees come as sponsored refugees under the
resettlement and other support for refugees around Refugee and Humanitarian Resettlement stream: 7,500 as

45
 Ruth Marie Wilson, Rabea Murtaza and Yogendra B. Shakya

Figure 1: Permanent Resident Arrivals in Canada, Ages 15-24, by Category, 1999-2008

40,000

35,000

30,000

25,000

20,000

15,000 Refugee dependents

Refugees landed in Canada

10,000
Privately sponsored refugees
5,000
Governement-assisted refugees
0
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
Source: Citizenship and immigration Canada. Developed by Access Alliance.

Government-Assisted Refugees (GARs) and 3,500 as The country situation was not good and
Privately Sponsored Refugees (PSRs). Roughly 12,000 to we had to worry all the time. The bad
19,000 come to Canada through the In-Canada Asylum news, the torture, the oppression did not
stream in which people apply as refugee claimants upon only affect our physical being but also our
entering Canada and then become permanent residents mental being.
once their claim process is approved by a quasi-judiciary Refugees (adults and youth) from all three communi-
body called IRB. The remaining 5,000 settle in Canada as ties also pointed out that experiences of living for
family dependents of people who have come as refugees protracted periods in under-serviced refugee camps in
(CIC 2008). transition countries as stateless individuals resulted in
diminished rights and opportunities, increased exposure
Pre-Migration Factors Influencing to discrimination and abuse, and undermined mental
Mental Health health. An Afghan refugee mentioned how:
Responses from participants in both studies indicate In Pakistan they dont treat Afghani [sic]
that many of the newly arrived refugees in Toronto have people the right way. They tell them why
undergone difficult and traumatic pre-migration experi- you are here? You destroy your country,
ences that constitute salient risks and stressors to their now you want to destroy ours? They dont
mental health. Many adult and youth refugees shared like Afghani people
personal stories of having experienced or witnessed war, Another participant likened the confined life in
torture, violence, targeted persecution, forced labor, refugee camp to living in a pigs pen:
forced migration and family separation. One Afghan But, life in refugee camp was like the pigs
refugee summed the immense impact of thirty years of pen. {Idioms ~ strictly confined in a place
war in Afghanistan in the following way: where you have no way out}. It was very
Of course there was war in Afghanistan difficult to travel and work. ..This was the
for almost thirty two years and people greatest oppression. We had to live in
lost family, people lost their homes confined refugee camps
and they experienced a lot of difficulties. One refugee youth recalled how he had to do difficult
That is one of the most challenge manual labor (without anything to eat) that exceeded
of their life. his capacity:
Participants discussed numerous mental health In [the refugee camp], you go and work
impacts of these pre-migration stressors including worry, outside, you get nothing to eat, but you
sadness, depression, and going crazy. According to have to handle heavy work, and thus you
one participant: do you grow wellIn [the refugee camp],

46
 Pre-Migration and Post-migration Determinants of Mental Health for Newly Arrived Refugees in Toronto

people sometimes help you out. But, the be sources of poor mental health among refugee youth
point is, you have to carry too heavy (Hymen et al., 1996). Findings from our two studies add to
things that you cant carry. this body of evidence. In referring to the compounding
Beiser, Simich, and Pandalangat (2003) research on pre-migration and post-migration challenges that she
Tamil refugees in Canada also identified similar pre- faces, one refugee participant summed up her sense of
migration determinants of mental health including war, despair in the following way:
displacement (within and outside of country of origin), Whenever I think about my problems and
living as IDPs or in refugee camps, harassment from what is going on right now, I almost get
authorities, family separation, and economic hardship. crazy. Not only getting crazy, I dont even
Existing studies on refugee mental health have want to live anymore.
found strong correlation between traumatic pre-migra- While being selected for resettlement in Canada is
tion experiences and PTSD. For example, a study of viewed positively by most government assisted refugees
Tamil refugees in Canada found that during pre-migra- (GARs), particular policy anomalies and process chal-
tion, 1/3 of participants had directly witnessed a lenges related to refugee resettlement in Canada
traumatic event such as rape or combat, and 12% of the themselves appear to worsen rather than alleviate mental
study group suffered from PTSD (compared with a health issues that refugees face. Stressors related to refugee
general population prevalence rate of 1%) (Beiser, resettlement process include delays in processing applica-
Simich, and Pandalangat 2003). Rummens (2007) found tions, errors in the paper work, delays in family
that 50% of refugee children who have witnessed reunification, lack of information, and having little or no
violence are likely to experience PTSD. In fact, in the input into which province or city GARs get settled in
United States the rates of PTSD range from 25% to 50% Canada. Our study on GARs mental health also found that
among refugee children and youth (Kinzie, Jaranson, & the transportation loan (covering airfare and initial settle-
Kroupin). Torture was found to be the strongest pre- ment costs for the family) that GAR families are required
migration predictor of PTSD (Lidencrona, Ekblad, and to repay was a major source of worry, anxiety and stress.
Hauff 2008) and is unfortunately a common refugee Several participants from this study recall that the
experience: 20% of all refugees are believed to be contractual obligation to take and repay the transporta-
primary or secondary victims of torture (International tion loan was signed more out of vulnerability and
Rehabilitation Council for Torture Victims 2008). desperation rather than through informed choice.
In both studies, refugees also highlighted some There are a number of documents that
positive aspects of their lives before arriving in Canada. In need to be signed when you are in the
particular, they talked about the strong family and process to come to Canada. You because
community bonds and supports that they develop in you are so desperate to come to Canada
refugee camps. To this extent, leaving family and they make you sign some documents in
community behind to come to Canada appear to have Egypt. You just sign any document
serious emotional impacts on refugees. [including the loan document] just to
Service providers highlighted that the bulk of come to Canada.
pre-migration mental health issues go undetected and Findings from both research projects indicate that
unaddressed. This is primarily due the limited the critical post-migration mental health stressors that
understanding and capacity of settlement and healthcare newly arrived refugees in Canada face include labor
providers to address mental health issues faced by market challenges (difficulties finding decent jobs, non-
refugee groups. recognition of foreign credentials, having to make do with
precarious jobs), poverty, linguistic barriers, difficulties
Post-migration Factors Influencing in learning (particularly learning English), adaptation to
Mental Health of Refugees new culture/context, isolation and discrimination. While
Existing literature on refugee health suggests that non-refugee groups may also face these barriers and chal-
post-migration factors impacting refugees may compound lenges, our findings reveal that refugee groups experience
mental health issues faced by this group (Canadian Task these determinants in acute and unique ways. The acute
Force on Mental Health Issues Affecting Immigrants and impact on refugees result from traumatic experiences that
Refugees in Canada 1998, Gifford, Bakopanos, Kaplan & refugees may have faced and/or due to gaps in educa-
Correa-Velez 2007). Further, in the context of resettle- tional, economic and political opportunities before
ment, experiences of poverty, interracial conflict, family coming to Canada
instability, parental psychosocial distress, youth unem- For example, while non-refugee newcomers may also
ployment and intergenerational conflict were all found to face linguistic barriers, refugees face this barrier in acute

47
 Ruth Marie Wilson, Rabea Murtaza and Yogendra B. Shakya

ways because many of refugees arrive with limited face. An Afghan refugee mentioned that:
education, low literacy and low English language fluency. Since September 11, most people are even
The following quote illustrates the intense difficulties that afraid to go to the mosque to pray. They
refugees face in learning English even though they are are in fear of being accused of terrorism.
trying their best and their teachers are giving their best: Based on ones social position, marginalized people
The language barrier is the most difficult may face multiple layers of discrimination and disadvan-
circumstance for me in Canada. It tage. The label of refugee itself can become an added
becomes a big worry and concern for me layer of discrimination that refugee groups face. For
and some times I get mad at myself...I try example, a female refugee youth from Sudan character-
my best, I dont seem to improve my ized the multiple discrimination and disadvantage she
language skills the teachers try their faces in the following way:
best in class, but we just dont under- That is what I am saying double disad-
stand them and lost concentration vantage. First you are refugee second you
A service provider working closely with refugee are black and third you are female. Have
groups highlighted the impact of trauma on learning so many things pushing you down.
capacity for refugees: Many refugee youth pointed out that education
In general we know that trauma has an and studying hard were their strategy for achieving
effect on peoples concentration and happiness in Canada and going beyond past experiences
memory and ability to learn language. So of hardships. However, multiple barriers including
in my experience with working with financial pressure and discrimination hinder their
refugees, people who experienced trauma, academic aspirations.
I did work with people who were highly A Sudanese refugee youth pointed out how teachers
educated, they were professionals in their sometimes perpetuate racism instead of helping to fight it:
countries. They came to Canada and were Teachers assume that you are stupid
unable to move from level one to level two, when you are black.
and that contributed to their depression The following quote by a Sudanese female youth
because some of them put lots of effort into exemplify how acute income insecurity and lack of
learning new language, but because of supportive systems can force newly arrived youth into
trauma, still they didnt know it was having to choose between shelter, food or school:
because of trauma, they were not able to Financial way school wise you have to
learn language, new information, concen- buy books and you cant buy certain
trate, you know memorize new things. And books because you are thinking of okay, if
it just contributed to their depression I spend this amount of money. Because
Others researchers have shed light on the relation- OSAP they didnt tend to give out enough
ship between trauma and learning (Freire 1990; Mojab money and to buy books and laptop and
and McDonald 2008; Stone, 1995). They emphasize that here you are and working limited job and
language training and other training programs geared at dont have enough money and trying
refugees need to be grounded on pedagogical framework differentiate which one come first: shelter,
that incorporates potential histories of trauma, inter- food or school. So in that cases you buy
rupted schooling, multiple language backgrounds, gaps in certain books and the rest, library,
literacy platforms, disassociation, and difficulty in photocopy, all this. So it is really a lot of
concentrating. pressure. Sometimes you just tend to drop
Due to limited literacy and English language fluency out and take a semester off and think
combined with gaps in educational and career experiences okay, if I work I might be able to help.
before coming to Canada, refugee groups are more likely
to face additional barriers in the labor market and experi- Recommendations
ence unemployment and poverty levels that are much Findings from the two research projects on refugee
higher than for non-refugee groups. An internal client mental health indicate that (1) newly arrived refugees in
survey conducted by Access Alliance in 2008 found that Toronto have faced critical pre-migration stressors
over 70% of refugee clients remain unemployed even after including war, violence, torture, persecution, precarious
3 years of arrival in Canada. migration and protracted stay in underserviced refugee
Findings from both studies indicate that discrimina- camps; and (2) pre-migration determinants, particularly
tion is a salient stressor that both adult and youth refugees gaps in educational and economic opportunities, exacer-

48
 Pre-Migration and Post-migration Determinants of Mental Health for Newly Arrived Refugees in Toronto

bate post-migration stressors that refugees face. International Rehabilitation Council for Torture Victims.
To this extent, we recommend the following: Remember tortured refugees. 2009. http://www.irct.org/
Default.aspx?ID=159&M=News&PID=549&NewsID=1405. (19
a. Implement innovative refugee-centred mental health
June 2009).
services and community empowerment strategies that
can enable refugee families overcome pre-migration Kinzie, J.D., Jaranson, J., and Kroupin, G.V. 2007. Diagnosis and
mental health issues (particularly PTSD and other Treatment of Mental Illness. In P. Walker & E. Barnett (eds.),
trauma) Immigrant medicine. Philadelphia: Saunders. 639-651.
b. Enhance resettlement policies and process in ways that
Lidencrona, F., Ekblad S., and Hauff E. Mental health of
minimize risk for refugee families, including getting rid
recently resettled refugees from the Middle East in Sweden: the
of the transportation loan repayment requirement. impact of pre-settlement trauma, resettlement stress and
c. Make settlement services including English/French capacity to handle stress. Social Psychiatry and Psychiatric
language training and employment preparation ser- Epidemiology 43 (2008):121-131.
vices more sensitive to the unique needs of refugee
population Mojab, S. and McDonald, S. 2008 (in press) Women, Violence
d. Recognize that settlement is a health issue and and Informal Learning, in K. Church, N.Bascia, and E. Shragge
(Eds.) Learning through Community: Exploring Participatory
promote active collaboration between health and set-
Practices. Springer Press
tlement sector.
e. Implement anti-racism/anti-oppression process for Rummens, J. A. 2007. Research on immigrant and refugee
proactively overcoming the multiple layers of discrimi- health in Canada. [Powerpoint Slides] presented at the
nation that refugee groups face. McMaster Refugee Child Health Conference, Settlement and
f. Design services within rights-based, equity framework Integration Services Organization (SISO), Hamilton, Ontario,
in ways that enable refugee groups to overcome percep- May 23, 2007.
tions of dependency and helplessness that they might Stone, N. 1995. Teaching ESL survivors of trauma. Prospect. 10,
be feeling. 3. (The Journal of the National Centrefor English Language
g. Engage marginalized refugee groups in critical path- Teaching and Research, Macquarie University)
ways (including research, policy development plan-
ning, decision making, etc) to promote social inclusion.

FOOTNOTES
1
Both CBR projects employed qualitative methods comprising
References
of focus groups and interviews; the research on refugee youth
Canadian Task Force on Mental Health Issues Affecting Immi- included a short survey. The research on adult refugees
grants and Refugees in Canada. 1988. After the door has been (Co-Principal Investigators: Dr Carles Muntaner and Dr
opened: mental health issues affecting immigrants and refugees Yogendra Shakya) was funded by the Centre for Addiction and
in Canada. Health and Welfare Canada. Mental Health and completed in 2008. The research on
refugee youth was initiated in 2008 (Co-Principal Investiga-
Beiser, M., Simich, L., and Pandalangat, N. Community in tors: Dr Sepali Guruge, Dr Michaela Hynie, Rabea Murtaza
distress: mental health needs and help-seeking in the Tamil and Dr Yogendra Shakya) with funding from Laidlaw Founda-
community in Toronto. International Migration 41.5 (2003): tion and Citizenship and Immigration Canada and is expected
233 245. to be completed by March 2009.

Freire, M. Refugees: ESL and Literacy Trying to Reinvent the

Self in a New Language. Refuge 10.2 (December 1990): 3-6.

Gifford, S., Bakopanos, C., Kaplan, I., and Correa-Velez, I.

Meaning or Measurement? Researching the Social Contexts of
Health and Settlement among Newly-arrived Refugee Youth in
Melbourne, Australia. Journal of Refugee Studies 20.3 (2007):
414-440.

Hyman, I., Beiser, M., & Vu, N. (1996). The Mental Health of
Refugee Children in Canada. Refuge 15.5 (1996): 4-8.

49
Immigrant Access to Mental
Health Services: Conceptual
and Research Issues
Alice W. Chen is currently adjunct professor and university research associate in the Faculty of Health Sciences at Simon Fraser
University. She received her doctoral degree in healthcare and epidemiology from the University of British Columbia. Her research
activities have included healthcare utilization by immigrants, indicators of childrens mental health and linkage of secondary databases.

abstract
The concept of access to mental health services includes cultural responsiveness and effectiveness as well as mental health promotion
and prevention. Research on immigrant access must consider cultural factors which affect the next generation and must examine
mental health outcomes. Improving immigrant access will ultimately benefit all Canadians.

Under the Canada Health Act, Canadians have come Extant knowledge has spurred various initiatives by
to expect reasonable access to health services without health service providers and policy-makers to reduce the
financial or other barriers (Canada Health Act 2009). identified barriers and increase the use of mental health
However, achieving that goal remains a challenge. In services. However, these responses may be inadequate
2000/01, 12% of Canadians aged 12 and over reported because of the restricted interpretation of access to
unmet health care needs. This rate is almost triple that mental health services and the related shortfall in
when the indicator was first measured in 1994/95 research evidence. This article will advocate for broadened
(Sanmartin, Houle, Tremblay and Berthelot 2002). The concepts of access and mental health services and will
reasons identified for the needs being unmet were recommend some directions for future research to fill the
predominantly access issues, including long waiting times gaps in knowledge. It will conclude that the research and
and services being unavailable, inaccessible or inadequate policy agenda for immigrant access to mental health
(Sanmartin, Houle, Berthelot and White 2002). services is ultimately the agenda for all Canadians.
Access to mental health care is even more disap-
pointing. In a related survey, 21% of Canadians with Conceptual Understanding of Access
symptoms of mental disorders or substance dependencies At present, the discourse on immigrant access to
reported unmet needs for their problems (The Daily 2003, mental health care is largely focussed on individual
Statistics Canada). In this context of overall challenges in deficits, such as language and cultural barriers. The
accessing mental health services, are immigrants difficul- response strategy, accordingly, is to help immigrants
ties to access unique? Generally, immigrants access is overcome these deficits through programs such as
treated separately in research and policy literature language/cultural interpretation or community out -
because of evidence that the difficulties are more acute reach. The goal of this approach is to connect
and imply different response strategies. immigrants with available mental health services and
Data in Canada have shown that immigrants and access is measured in terms of the use of existing
ethnic minorities are underrepresented in the mental services. However, a popular model of health service use
health care system or are less likely to use mental health suggests that access is more than the output of the
services. Even among those who experienced a major healthcare system in that the number of clients served is
depressive episode, it was found that Chinese immigrants, not equivalent to the level of access.
for example, were less likely to consult health profes- According to this model proposed by Andersen and
sionals (Chen, Kazanjian and Wong 2009; Tiwari and Davidson, access to healthcare involves both individual
Wang 2008). Numerous other studies have examined the and contextual components (Andersen and Davidson
barriers that deter immigrants from benefiting from 2001). While individual characteristics (such as age,
mental health services, including language, health beliefs, gender, health beliefs, financial means) predispose and
family dynamics and indirect financial costs. enable a person to seek healthcare, contextual characteristics

51
 Alice W. Chen

(including the delivery and organization of healthcare) Conceptual Understanding

strongly influence the use of healthcare as well. Andersen of Mental Health Services
and Davidson also define access as: The expansion in scope of the concept of mental
actual use of personal health services and health to include mental wellbeing opens up another area
everything that facilitates or impedes in which the unique needs of immigrants must be under-
their use..Access means not only getting stood and addressed. The World Health Organization
to service but also getting to the right defines mental health as:
services at the right time to promote a state of well-being in which the indi-
improved health outcomes (p.3). vidual realizes his or her own abilities,
This definition espouses several quality indicators of can cope with the normal stresses of life,
health system performance proposed by the Canadian can work productively and fruitfully, and
Institute of Health Informationavailability, accessi- is able to make a contribution to his or
bility, appropriateness, acceptability, competence, safety her community (World Health Organi-
and effectivenessas essential components of access zation 2007).
(Canadian Institute of Health Information 1999). Taking The Public Health Agency of Canada defines mental
this broad view of access and considering the criteria health as:
involved, current approaches to improve immigrants the capacity of each and all of us to feel,
access are profoundly inadequate. think, and act in ways that enhance our
Despite the fact that all health services offered in ability to enjoy life and deal with the
Canada are available to landed immigrants, their use of challenges we face. It is a positive sense
mental health services consistently lags behind that of the of emotional and spiritual well-being
general population. While the goal of the current approach that respects the importance of culture,
is to make existing services more accessible, the funda- equity, social justice, interconnections
mental question is whether the right services are available, and personal dignity (Public Health
that is, whether the services offered are appropriate and Agency of Canada 2006).
acceptable. Immigrants from certain cultural backgrounds The discourse on immigrant access to mental health
tend to express their psychological distress as somatic service has to date largely focussed on remedial services
symptoms. They may resist the medical approach to for those who experience mental health difficulties. To
psychological problems or the stigma of psychiatric ensure that immigrants achieve optimal mental health
treatment. At the same time, their psychological distress and live to their full potential in Canada, attention must
often stems from real social stressors. Under these complex be paid to their access to mental health promotion and
circumstances, making the right diagnosis and providing prevention initiatives.
the right intervention may require multifaceted efforts. The strategies for promoting mental health
Existing mental health services, which are built around the typically targets the determinants of health, such as
medical model, are often not appropriate or acceptable. employment, housing, education, social support. These
Appropriate and acceptable therapies, including traditional are also issues of particular salience to immigrants who
and alternative treatment and psychosocial interventions, are in transition in all these spheres. Many of the
are usually not covered by health plans. Moreover, many hurdles immigrants face during this vulnerable phase
health practitioners in Canada called to care for immi- recognition of credentials, finding full employment,
grants and refugees are not trained in cross-cultural affordable housing, language training, building social
service provision or in the specialized areas pertinent to networks, integration with the local community, accul-
this vulnerable group, e.g. post-traumatic stress disorder. turation, discriminationare in fact critical points of
Despite the best intentions, care provided may not be intervention to achieve the goals of mental health
competent or safe. Taking into account these nuances of promotion and prevention. Successful immigrant settle-
access, it is fair to conclude that access to the right mental ment, in addition to benefiting the socio-economic
health services for immigrants is limited at best. Finally, future of Canada, contributes also to the health of the
Andersen and Davidson state that access is ultimately population. Current research suggests that immigrants
evaluated by the improved outcome of the service. mental health worsens over time. Although there is no
Increasing immigrants use of existing services does not direct evidence that attributes the decline to their settle-
necessarily mean they have access to effective services. In ment experience, concerted efforts to facilitate this
fact, current statistics on immigrants use of mental health transition may help immigrants maintain their health
services may overestimate their true access to services that advantage.
meet all the criteria implied in the broad definition.

52
 Immigrant Access to Mental Health Services: Conceptual and Research Issues

Research on Factors that Influence Access Cultural orientation, which is transmitted to the next
Much about immigrants access to mental health generation, may be the major barrier not only in the first
services or lack thereof is still unknown. Two areas of generation of immigrants, but also in the Canadian-born
research are particularly needed to inform the develop- ethnic minority population. By focussing only on immi-
ment of appropriate strategies for improving access: grants, the mental health needs of the next generation of
specifying the role of factors that influence access and Canadians may be overlooked, and the effort to improve
measuring the outcome of intervention. access to mental health care for all Canadians is unneces-
Although there is general agreement that immi- sarily hampered. Currently, the cultural aspect of mental
grants are disadvantaged in terms of access to mental health service provision is discussed only in relation to
health services and many barriers to access have been aboriginal Canadians and immigrants. As Canada
identified, there is still no clear understanding of the role becomes increasingly diverse, culture will have to be on
that these factors play or the factors most responsible for the agenda for access to mental health service for all.
lack of access. The complexity of health service use and Research on immigrant mental health has much to
access is one obvious reason why the pathway to access contribute to this agenda and the potential to lead the
has not been articulated. For responsive strategies to effort to improve the mental health system.
be developed, it is important for researchers to begin to
tease out the many influences on access. Clarifying the Research on Mental Health Outcomes
contribution of two general categories of influences is Another area where research is needed is in evalu-
helpful as a start: migration and culture. ating the outcomes of the mental health system. As
The majority of recent immigrants to Canada come mentioned before, the ultimate test for access is in
from non-European origins and are ethnically and cultur- improved mental health outcomes. This outcome evalua-
ally different from the (majority) resident Canadian tion refers not only to assessing the effectiveness of
population, for whom the health system is designed. As a specific programs and interventions. While such evalua-
result, the issues of migration and cultural diversity are tions are important to ensure that the health system
intertwined in the discourse on access to care. Owing to invests in services supported by strong evidence in the
constraints in research design or data availability, current immigrant population, the mental health outcome of the
research on access to care often fails to separate the immigrant population must also be tracked to ascertain
effects of the two, even though there is evidence that not the overall level of access, both to clinical services and to
all immigrants experience lower levels of access. White promotion and prevention policies and strategies.
immigrants, for instance, are statistically indistinguish- Findings on the use of specific services and programs
able from the Canadian-born White population in mental will have to be interpreted in a larger body of research
health service use. Even among visible minorities, Chinese examining the mental health outcome of patterns of
immigrants have lower rates of use than South Asian and such service use. Underrepresentation in formal mental
Southeast Asian immigrants (Tiwari and Wang 2008). If, health care does not necessarily indicate lack of access
as the earlier discussion on conceptual understanding of if the immigrant population demonstrates improvement
access highlights, challenges to access arise from cultural in mental health outcomes overall. In fact, decreased use
discordance as much as factors associated with the of professional mental health care is expected if strate-
migration experience (e.g. language fluency, knowledge of gies to promote mental health and prevent disorders
health system), different strategies will have to be imple- are successful.
mented to counter the challenges. For instance, while To achieve the purpose of identifying the factors
language barriers are regarded as deterrents to using that contribute to use of mental health services and
mental health services, having primary care doctors who monitoring the mental health outcome of the immigrant
speak ones native language has been shown to decrease population, there must be relevant data. The challenges
the use of mental health services, likely as a result of the of acquiring data on minority populations have hindered
doctors cultural orientation and practice (Chen and many research endeavours. This effort can be much
Kazanjian 2009). Such paradoxical findings illustrate the more efficient if stakeholders in multiple sectors can
need to take apart the many influences on access to care. collaborate to collect relevant data at a population
Conversely, challenges to access are not unique to level. For instance, many national immigrant and
the immigrant population. Other than the overall high health surveys by Statistics Canada already collect
level of unmet mental health needs in the general popula- detailed information on ethnic background and immi-
tion, there is evidence that underuse of existing mental gration status. More emphasis can be given to mental
health services persists in the second generation of health in these surveys to help reveal the mental health
Chinese immigrants (Chen, Kazanjian and Wong 2009). outcomes of current health policies and system.

53
 Alice W. Chen

Conversely, reliable measures of immigrant status and Bibliography

ethnic identity can be introduced to administrative Canada Health Act Chapter C-6. Minister of Justice. November
databases on healthcare to facilitate understanding of 11, 2009. http://laws-lois.justice.gc.ca (9 Dec. 2009).
the patterns of healthcare use. While there must
be safeguards against the misinterpretation and misuse Canadian Community Health Survey: Mental Health and Well-
of such information, the lack of such information being. The Daily (Statistics Canada), September 3, 2003, p. 2-4.
can be more detrimental to the wellbeing of the Andersen, R.M., and P.L. Davidson. 2001. Improving Access to
minority populations. Care in America: Individual and Contextual Indicators. In T.H.
Rice and G.F. Kominski (eds.), Changing the US Health Care
Conclusion System. San Francisco: Jossey-Bass. 3-30.
This article has outlined a broader concept of access
to mental health services to be applied to the discussion Canadian Institute of Health Information. 1999. National
Consensus Conference on Health Indicators: Final Report.
regarding the immigrant population and access to mental
Ottawa: CIHI.
health care. Improving immigrant access to mental health
services should not be confined to increasing the number Chen, A.W., and A. Kazanjian. Do Primary Care Providers Who
of immigrants who contact existing mental health Speak Chinese Improve Access to Mental Health Care of
services. It must also assess the responsiveness of services Chinese Immigrants? Open Medicine 3.1 (2009): E1-9.
and the effectiveness in improving the mental health
Chen, A.W., A. Kazanjian, and H. Wong. Why do Chinese-
outcomes of the immigrants. Similarly, current emphasis
Canadians not Consult Mental Health Services: Health Status,
on promoting mental wellbeing in the population should Language or Culture? Transcultural Psychiatry 46.4 (December
also dovetail with immigration settlement, in order to 2009): 623-641.
address many of the determinants of mental health that
uniquely affect the immigrant population. Mental Health Commission of Canada. 2009. Toward Recovery
Research will have to support health service and Well-being: A Framework for a Mental Health Strategy for
providers and policy-makers by elucidating the relative Canada.
contribution of different influences on access to mental Public Health Agency of Canada. 2006. The Human Face of
health services. The research agenda on barriers to Mental Health and Mental Illness in Canada. Ottawa: Govern-
mental health services should include not only immi- ment of Canada.
grants but eventually the culturally diverse Canadian
population. Research must also focus on the mental Sanmartin, C., C. Houle, J. Berthelot, and K. White. 2002.
Access to Health Care Services, 2001. Ottawa: Statistics Canada.
health outcomes of the immigrant population, in
addition to the barriers to existing mental health Sanmartin, C., C. Houle, S. Tremblay, and J. Berthelot. Changes
services and the effectiveness of specific interventions. in Unmet Health Care Needs. Health Reports 13.3 (March
Policy-makers in turn can assist research efforts by facil- 2002): 15-21.
itating the collection of relevant data.
Tiwari, S.K., and J. Wang. Ethnic Differences in Mental Health
The framework for a mental health strategy in
Service Use Among White, Chinese, South Asian and South
Canada recently released by the Mental Health Commis-
East Asian Populations Living in Canada. Social Psychiatry and
sion of Canada endorses this broad view of access and the Psychiatric Epidemiology 43 (2008): 866-871.
scope of the population (Mental Health Commission
2009). Individuals and groups experience mental health in World Health Organization. Mental Health: Strengthening
different ways. Migration-related stresses pose particular Mental Health Promotion. Fact sheet No. 220. September 2007.
risks to immigrants and refugees. Mental health systems, http://www.who.int/mediacentre/factsheets/fs220/en/print.html
therefore, must be responsive to the diverse needs of all (9 Dec. 2009).
Canadians, including immigrants, the second and third
generations, aboriginals and other individuals whose
needs differ from the mainstream. Under this framework,
it is hoped that innovative strategies to improve access
will be found and the mental health outcomes of all
Canadians will be improved.

54
Cultural Competence in Mental
Health Services: New Directions
Charmaine C. Williams, PhD is an Associate Professor and Associate Dean Academic at the Factor-Inwentash Faculty of Social Work,
University of Toronto. She conducts and publishes research in the areas of mental illness, cultural competence, HIV prevention in Black
communities, and access to health care for racial and ethnic minority populations.

abstract
This article describes existing problems with cultural competence definitions and examines new developments in cultural competence
theory and practices that have the capacity to increase the mental health care systems proficiency in serving racial and ethnic
minority clients.

Cultural Competence: The First 20 years professionals bring to their work with clients from
Shifts in Canadian immigration policy have different cultures (Husband 2000). This approach,
increased the number of newcomers arriving from non- however, has proven inadequate for several reasons.
Western nations and nations identified as part of the First, the cultural content that has been used to
global south, greatly increasing the racial, ethnic and educate service providers is often based on static repre-
linguistic diversity of this nation. Accordingly, the health sentations of culture that either reinforce stereotypes or
care system is working to respond to meet the needs of dominant group experiences, not taking into account
our diverse population. Moreover, there is recognition of a within-group diversity or dynamic transformations in
particular need to be equipped to address mental health culture that accompany changes in environment
concerns in newcomer populations. Immigrants and (Williams 2006). Second, this version of cultural compe-
refugees are often coming from situations in which they tence has not addressed the power dynamics that are
have survived tremendous environmental stress, political associated with identification of cultural difference and
persecution and other types of hardship, and the immi- how these dynamics of racialization and marginalization
gration process itself and stressors associated with are associated with oppressive experiences within and
settlement in a new environment can increase vulnera- beyond the mental health care system (Williams 2002).
bility to mental health problems (Perez Foster 2001). Third, this discourse has done little to address the
The mental health care system has responded to question of effectiveness in service delivery. Although
these challenges by articulating the need for cultural there is some understanding that retaining racial and
competence at all levels of service delivery. The now ethnic minority clients in services is a minimal indicator
classic definition of cultural competence identifies it as a of culturally competent service delivery(Williams 2001),
set of integrated behaviours, attitudes and policies that research is revealing that these clients do not consis-
enable a system, agency, and professionals to work effec- tently receive equal benefits from service as those
tively in cross-cultural situations (Cross, Bazron et al. individuals who are identified with the racial/ethnic
1989). This definition has been adopted by many North majority (Bhui and Morgan 2007). This is especially
American health care systems and is evoked regularly in troubling as effectiveness is becoming a major focus of
discussions surrounding the delivery of mental health mental health care service design, reinforced by the
care in multicultural environments. Yet, many have growing availability of evidence-based practices that we
struggled with how to translate these guidelines into know are highly effective in alleviating mental distress
hands-on strategies that would alter mental health and illness (Muoz and Mendelson 2005). Unfortunately,
services to make them more effective for ethnic and racial efforts at increasing the cultural competence of the
minority populations. Many of the efforts to operation- system seem to run parallel to efforts to increase the
alize cultural competence have resulted in the effectiveness of services in the system with little thought
development of programs to equip service providers with to how these agendas can be merged to increase equity
cultural knowledge about various groups, with the hope in the mental health care system. Therefore, although
that increasing cultural literacy at the service frontline the mental health care system has greatly increased its
will improve the level of understanding that mental health awareness of the need to evolve to meet the demands of

55
 Charmaine C. Williams

an increasingly diverse population, the efforts to date ical contributions that can aid practitioners to recognize
have done little to address Crosss (1989) assertion that culture being lived and created in multiple forms.
cultural competence involves attention to both the Although culture can be defined in a specific body of
cultural context of treatment and its effectiveness. The knowledge, it also manifests and changes based on
most common iteration of cultural competence falls consensus within and across groups, it is defined intersub-
short of equipping the system to adequately serve many jectively within specific interactions, it develops in
member of our growing Canadian population. response to dominance and oppression in different
contexts, and it can be as unique as the individual we are
New Contributions to the Cultural trying to know (Williams 2006). All these ways of
Competence Agenda knowing culture are relevant to mental health care
Twenty years after Cross defined cultural compe- practice because of the importance of finding ways to gain
tence, new developments in theory, research and practice knowledge of clients that will aid in understanding
are converging to enrich the cultural competence agenda how illness and health is defined in the context of
and address the concerns noted above. Notable new intrapersonal, interpersonal, intragroup, and intergroup
contributions in this area include evolving definitions of environments. Both intersectionality theory and the epis-
how culture should be understood as part of the practice temological lens on culture re-define cultural competence
context, indigenous additions to defining the scope of as multiple competencies that can support a range of
competence for practice with racial/ethnic minority responses to a range of cultural expressions and experi-
populations, and research-based efforts to increase the ences. Although such contributions undoubtedly make
accessibility of evidence-based practices by culturally cultural competence more complex, they also have the
adapting some of our most effective interventions. potential to make it more precise in its efforts to incorpo-
rate culture into practice.
Dynamic, Multidimensional Definitions of Culture
There needs to be attention to specific cultural The Emergence of Cultural Safety
practices that affect the experience of mental health Another important development has been the itera-
problems, culture-bound syndromes that may appear in tions of standards for cross-cultural practices from
practice settings, and cultural dynamics that affect the indigenous populations, most completely articulated by
helping relationship, as defined via cultural formulation Maori health practitioners in New Zealand who have
(Lewis-Fernndez and Daz 2002). However, theoretical developed standards for what they term cultural safety
developments articulating how culture is experienced (Kearns and Dyck 1996). Cultural safety acknowledges the
through intersectionality and in varying epistemological importance of work already underway to recognize the
frames are broadening our understanding of what it points of disconnection between mainstream mental
means to engage with someone at a cultural level. health care and health paradigms used by many racial and
The intersectionality discourse is critical of the ethnic minority groups. It asserts, however, that these
culture in cultural competence being identified primarily efforts must also recognize the power dynamics inherent
with racial and ethnic difference signaled by accent, in service delivery systems that are primarily organized
physical appearance, etc. and urges practitioners to and executed by racially, ethnically and political
recognize culture more inclusively, in the attitudes, dominant groups who bring their higher social status into
behaviours, characteristics and shared experiences of interactions with members of racial and ethnic minority
groups defined by other social markers like sexuality, age, groups. The consequences of this power and status
class, religion, etc. (Kelly 2009). Layers of cultural experi- manifest in the poor record that the mental health care
ence intersect so that the lived experience of any one is system has had with such groups, as demonstrated in
affected by the simultaneous experience of the others. research documenting their mistreatment, misdiagnosis
This understanding directs practitioners away from and poorer prognosis in Western mental health care
accepting essentialized, stereotyped definitions of systems (Williams 2002). The work of these Maori practi-
cultural experience and toward raising questions about tioners identifies negotiating this power dynamic as a skill
how gender, class, sexuality, religion and other social cate- that must be prioritized in training for service providers,
gorizations affect the way in which individuals access and as inattention to it easily leads to misuse of power,
adhere to cultural experience. This dynamic view of prejudice and discrimination that can alienate racial and
culture effects mental health practices by discouraging ethnic minority clients from seeking services and/or
the delivery of services in one-size-fits-all packages that completing treatment (Polaschek 1998). Cultural safety
cannot address the diversity of needs within a cultural holds practitioners of all racial and ethnic backgrounds
group. This line of theorizing converges with epistemolog- responsible for examining the power dynamics in practice

56
 Cultural Competence in Mental Health Services: New Directions

and recognizing their potential to contribute to systemic and the steps that must be taken to make evidence-based
and interpersonal racism that can disengage and harm practices culturally appropriate and responsive. Service
clients (Baker 2007). settings and systems can support practitioners in these
efforts by prioritizing training for cultural competence
Cultural Adaptation of Evidence-Based Practices and building relationships with newcomer and citizen
Finally, there is work underway to increase access to communities that will support them in remaining respon-
evidence-based practices by culturally adapting existing sive to mental health needs in racial and ethnic minority
treatment models so they are more culturally appropriate. populations. Improving cultural competence at service
Cultural adaptation involves strategies like building on and system levels is an ongoing process that will require
culture-specific models of health, integrating culturally- regularly reevaluating the competence standards we have
relevant rituals into treatment, using culturally syntonic in place and the strategies we are using to achieve them.
examples for psychoeducation, and developing interven- Diversity and equity have been named as priorities in
tion strategies to address population-specific stressors in health care planning at the provincial and federal levels,
the current environment (Muoz and Mendelson 2005). therefore a space has been created in which new contribu-
Evidence-based practices require cultural adaptation tions to cultural competence can be brought to attention.
because they have usually been developed in mainstream This should strengthen our resolve and our optimism
settings and tested with clients who identify with the about improving services available to immigrants and
dominant culture. The assumptions, examples, goals and other racial and ethnic minority groups in the mental
expectations for treatment embedded in these models do health care system.
not necessarily translate effectively to racial and ethnic
minority clients. Close examination of such work, for
example, the prevention and treatment manuals
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challenges in achieving those competencies (Williams
Muoz, R. F. and T. Mendelson (2005). Toward evidence-based
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suggesting that practitioners, in particular, need to under- Consulting and Clinical Psychology 73.5: 790-799.
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culture, the impact of power dynamics in their practice,

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58
Taking Culture Seriously
in Community Mental Health:
A five-year study bridging
research and action
Joanna Ochocka is Executive Director of the Centre for Community Based Research. Joanna was the Principle Investigator of the Taking
Culture Seriously in Community Mental Health project and is a Canadian leader in participatory action research using research as a tool
for social change, particularly in the fields of mental health, cultural diversity, and supports for marginalized populations.
Elin Moorlag is a Senior Researcher at the Centre for Community Based Research. Elin was involved in the CURA project as a graduate
student research from 2005-2009. As a mixed-methods sociologist, her research interests include the sociology of community, policy
analysis, Canadian multiculturalism, immigrant integration and settlement, mental health and diversity, and community-based and
participatory action research.
Sarah Marsh is a Researcher at the Centre for Community Based Research. Sarah was responsible for coordinating the Taking Culture
Seriously in Community Mental Health project from 2007-2009. She has also led a number of other projects at the Centre, including a
two-year evaluation of a Bridge Training program for internationally trained Social Workers.
Karolina Korsak worked on the CURA from 2006-2008 collecting data and assisting with analysis. She is currently involved in two of
the CURA demonstration projects, being a navigator for Strengthening Mental Health in Cultural-Linguistic Communities, and a
support group facilitator for the Mens and Womens support groups (run by the Multicultural Centre) project. Karolina is the recipient
of a SSHRC award, and as such will be pursuing a Masters degree in the social sciences beginning January 2010.
Baldev Mutta has been in the field of social work for over 30 years. He is the Founder and Executive Director of the Punjabi Community
Health Services (PCHS). For the last 20 years, he has developed an integrated holistic model to address substance abuse, mental
health and family violence in the South Asian community. PCHS was a integral community collaborator on the CURA project.
Laura Simich was a co-investigator on the Taking Culture Seriously in Community Mental Health project. She is a Cultural and Medical
Anthropologist with the Social, Equity and Health Section in the Social, Prevention and Health Policy Research Department, CAMH. Dr.
Simichs research focuses on community resources for mental health, social determinants of immigrant health, social support in
refugee resettlement, and mental health promotion for culturally diverse communities.
Amandeep Kaur, Manager, Punjabi Community Health Services. Amandeep has been a key contributor to the operations and growth of
Punjabi Community Health Services (PCHS) for more than 15 years. She has taken on several roles at PCHS, including designing and
delivering direct services, and managing programs.

abstract
Taking Culture Seriously in Community Mental Health (2005-2010) is a collaborative interdisciplinary project with over
40 partners conducted in two Ontario sites. With the project now coming to an end, this article presents a synopsis of empirical
findings, emergent theoretical implications, and recommendations for research, policy and practice within mental health services in
Canada.

59
 Joanna Ochocka, Elin Moorlag, Sarah Marsh, Karolina Korsak, Baldev Mutta, Laura Simich and Amandeep Kaur

Introduction approach (Kemmis & McTaggart, 2005) that sought to

In just one generation the cultural face of Canadian meaningfully involve stakeholders throughout the
society has changed dramatically. Community mental research process, and that placed an emphasis on
health organizations across Canada have been struggling producing useful results for positive change (Ochocka,
to respond to this new diversity. Western-trained service Janzen & Nelson, 2002). Five ethno-cultural communities
providers and program planners often do not understand were actively involved (Somali, Sikh- Punjabi, Polish,
the culturally specific meanings and stigma attached to Mandarin, Spanish Latin-American) in both Toronto and
mental illness practice (Beiser, 2003; Clarke, Colantonio, Waterloo Regions. Community researchers from all
Rhodes & Escobar, 2008; Hsu & Alden, 2008; Whitley, cultural communities in both sites (10 in total) were
Kirmayer & Groleau, 2006; Tiwari & Wang, 2008; Wu, integral to the entire data collection process. Community
Noh, Kaspar & Schimmele, 2003). As a result, many researchers were also key actors of community engage-
cultural groups lack access to effective mental health ment, serving as an important link between the research
services, even though community-based supports have project and the participating community (Ochocka, 2007;
the potential to improve their mental health (Li & Ochocka & Janzen, 2008).
Browne, 2000; Chiu, Ganesan & Morrow, 2005). Within the first phase, five methods were used
The reality of cultural diversity is coming at a time (international literature review, key informant inter-
when many community mental health service providers are views, focus groups, service provider surveys and case
embracing a new emphasis on personal empowerment (i.e., studies) to gather data from over 300 individuals.
consumers having voice and choice) and the full integration Analysis of this data resulted in the development of a
of people with mental illness into community life. Yet framework for improving mental health services for
mental health practice typically views cultural diversity as a cultural communities. In the second project phase, this
challenge to be overcome. Culture could rather be seen as framework was the basis for development of innovative
strength, by encouraging diverse cultural communities to demonstration project ideas intended to address many of
help create and shape culturally appropriate supports. This the challenges and issues identified. In total, twelve
means a serious commitment to cultural understanding, demonstration project proposals were submitted to
including a need for service providers to reflect on their funders, with six successful in securing external funding
own cultural assumptions. In short, community mental and currently underway in the Waterloo and Toronto
health practice needs to take culture seriously (Simich, Regions. The third and final project phase included a
Maiter, Moorlag, & Ochocka, 2009). second round of data collection, focusing on evaluation
of demonstration project planning and implementation.
Description of the Taking Culture Seriously Data collection methods for this evaluation included
in Community Mental Health Study interviews, focus groups and a tracking tool designed to
The purpose of the Taking Culture Seriously in monitor project activities over time.
Community Mental Health study was to explore, develop, This CURA study represents five years of simulta-
pilot and evaluate how best to provide more effective neous research and knowledge transfer from a
community-based mental health services for Canadas participatory action framework. One of the projects
culturally diverse population. The project, a five year goals was to emphasize the transferability of knowledge
SSHRC-funded Community University Research Alliance gained to all of multicultural Canada (Jacobson,
(CURA), was housed at the Centre for Community Based Ochocka, Wise & Janzen, 2007; Ochocka, 2007describe
Research. It was a collaboration among 45 partners from CURA beginnings). Strong knowledge transfer efforts
the Waterloo and Toronto Regions, including interdisci- included: bi-yearly CURA bulletins sent to over 300
plinary academics, ethno-cultural community groups, researchers, practitioners and policy makers in Ontario,
and leading practitioners (from mental health and settle- two professional theatre productions, a round table for
ment sectors). policy makers and senior bureaucrats, 10 community
From 2005 to 2010, the project was carried out in forums, two conferences, ten peer-reviewed articles
three phases: (1) exploring diverse conceptualizations of and over 40 conference presentations delivered
mental health problems and practice through primary nationally and internationally. A crucial element of the
data collection, (2) developing culturally effective practice success of this CURA was the ability to engage a
through collaborative proposal development with multidisciplinary team of leading academics, innova-
partners and community members, and (3) evaluating tion-focused mental health service providers and
demonstration project development and implementation. practitioners, and dedicated members of diverse ethno-
The Taking Culture Seriously in Community Mental cultural communities around a core vision of effecting
Health study used a participatory action research (PAR) change within the mental health system.

60
 Taking Culture Seriously in Community Mental Health: A five-year study bridging research and action

Results cultural-linguistic communities. Their collaboration in

innovating mental health policy and practice is character-
Development of the Framework ized by reciprocity in which the benefits and
Through analysis of the data compiled from the responsibilities of collaboration are shared (Maiter,
study, we proceeded to develop a framework to guide Simich, Jacobson & Wise, 2008). This type of reciprocal
future mental health policy and practice. Our intent was collaboration is the transformational process by which the
to develop a framework that was principle-driven, action- present context of disconnections is rectified and through
oriented and that could inspire future innovation which the values, actions and outcomes of the emerging
(scaffolding for demonstration projects was how one framework are achieved (for details see Janzen, Ochocka
partner put it). This theory-building process was highly et al., 2009, in press).
collaborative and is described in detail in one of our The Taking Culture Seriously in Community Mental
CURA publications (Westhues, Ochocka, Jacobson, Health study participants affirmed what our earlier litera-
Simich, Maiter, Janzen & Fleras, 2008). ture revealed: the need to develop a conceptual
Figure 1 graphically shows the Taking Culture framework that synthesizes notions of culture and power
Seriously in Community Mental Health framework. This if improvements to mental health policy and practice are
framework adequately addresses combined ideals of both to be made. Such a position resonates with recent mental
the culture-oriented and the power-oriented theories health discourse that, on the one hand, points out the
(Janzen, Ochocka, et al., 2007). It includes three main detrimental effects of abuses of power in the mental
components: values that guide concrete action that in health system and the need for critical voices to keep that
turn produces desired outcomes that serve to reinforce the power in-check and to remain consumer-centered
stated values. Central to the framework is the active (Bassman, 2001). On the other hand are growing calls to
involvement of mental health policy-makers/system take culture seriously and develop competencies towards
planners, mental health organizations/practitioners and more effective mental health policy and practice in

Figure 1: Taking Culture Seriously in Community Mental Health Framework

Values
Individual and community
self determination
Dynamic inclusion

Relational synergy
force

Gui
de
Rein

Reciprocal collaboration
Mental health policy-makers/planners
Mental health organizations/practitioners
Cultural-linguistic communities

Outcomes Actions
Improved acceptability and Enhancing communities
accessibility of services
Better mental health promotion
Reconstructing the mental
health system
and illness prevention Building reciprocal
Increased evidence that culture
relationships
is taken seriously

Produce

61
 Joanna Ochocka, Elin Moorlag, Sarah Marsh, Karolina Korsak, Baldev Mutta, Laura Simich and Amandeep Kaur

increasingly cross-cultural settings (CAMH, Report by committing to actions that advance reciprocal relation-
the Mental Health Commission of Canada Task Group on ship building between the mental health system and
Diversity, 2009). By synthesizing both culture and power cultural linguistic communities. While no one project
our framework stresses that the mental health systems illustrated the complete emerging theoretical framework,
responsiveness to diversity rests as much in naming and collectively they aspired to promote innovation at
addressing privilege and socio-economic inequalities, as it multiple levels of intervention.
does in understanding and managing cultural differences In total, twelve demonstration project proposals
(Maitra, 2008). The emerging theoretical framework lays emerged through collaborative efforts among CURA
out how mental health policy and practice can change to partners and additional collaborators and were
become more responsive to people from diverse cultural- submitted to funders. Some projects were initiated by
linguistic backgrounds. cultural communities, some by settlement and mental
health service organizations. Of the twelve demonstra-
tion projects that were developed, six were funded
Demonstration Project Implementation and are currently active beyond the end date of the
and Evaluation CURA study. Contained in Figure 2 is a representation
After building a theoretical framework and of each of the demonstration projects on the continuum
discussing its practical implications at community forums of mental health service delivery, from primary to
and a CURA conference, our CURA partners developed tertiary intervention.
demonstration projects. People clustered into sub-groups The CURA evaluation committee developed a
to develop a series of demonstration project proposals. common evaluation design to test and refine the projects
Each project was a collaborative effort that sought to emerging theoretical framework. The evaluation aimed to
examine both power and culture in practice, while 1) gain insights about the process of implementing the

Figure 2: The 12 CURA Demonstration Projects on the continuum of mental health service delivery

Province Wide Mental Health Punjabi

Theatre Leaderchip Cultural Community
& Development Navigators Health Services

Services across
the continuum:
Multi-level Intervention

Primary: Health Secondary: Tertiary: Access to

Promotion & Early Intervention Services & Support
Anti-Stigma
St. Josephs Somali
Cultural-Linguistic CMHA Grand River:
Settlement &
Groups Builiding culturally
Mental Health
responsive services

Newcomer Supportive CMHA Toronto:

Environmental Multicultural Older Adult
Youth Housing & Building culturally
Service Scan Mens & Womens Conversation
Theatre Diversity responsive services
Support Groups Circles

active CURA projets

unfunded proposals

62
 Taking Culture Seriously in Community Mental Health: A five-year study bridging research and action

emerging framework, 2) assess the degree to which study Our study results have implications specific to each
findings guided or influenced the demonstration projects, stakeholder group: policy makers, service providers and
and 3) assess the degree to which the study findings have cultural communities. Out of the data collected
enhanced the ability of demonstration projects to have an throughout this project, it is suggested that policy makers
impact on the mental health system and cultural need to facilitate changes at the structural level while
linguistic communities. Preliminary evaluation results simultaneously working toward better processes. This
were shared at a conference concluding the CURA project would involve developing flexible funding structures to
on December 4th, 2009, deepening our collective under- accommodate innovative, collaborative culturally-appro-
standing of the frameworks theory of changeof the priate practice. For instance, positive change would result
logical link between its values, actions and desired if funding requirements for organizations were to include
outcomes. Evaluation findings will be further described in benchmarks based on collaboration and power-sharing
future presentations and publications. for cultural-linguistic communities in decision-making.
Furthermore, the area of mental health and diversity does
Conclusions not neatly fall into one policy portfolio, so collaboration is
While the deeply ingrained current policies cannot paramount to develop effective policy that intersects
be expected to change overnight to make the mental across the health, education, immigration, and employ-
health services effective for multicultural Canada, one ment arenas.
important thing that this CURA study did was foster a Two recommendations for service providers are to
broad, cross-sectoral collaboration of a large number of engage in ongoing reciprocal outreach and collaboration
people in Ontario, without which any relevant changes with cultural-linguistic groups, and to challenge power
may not be possible at all. It also equipped and inspired and racism within and outside the organization. Increased
people for change due to the collaborative research mutuality can be achieved through cross-cultural consul-
production and knowledge mobilization efforts. In tations, sustained partnerships and the development of a
keeping with the core values of the emerging theoretical diverse work force. Key elements of challenging power
framework, throughout the project there were ample imbalances and racism include a recognition that
opportunities for reciprocal relationship building, cultural competency involves reciprocal collaboration,
dynamic inclusion of community members, mental health an emphasis on building community awareness around
providers and academics alike, as well as a necessary space mental health and service use, and promotion of holistic
for developing the self-determination that is crucial understandings of wellness/illness.
within cultural communities for change to occur. This According to our data, cultural communities must
CURA initiative demonstrated how community based also take responsibility for increasing the effectiveness of
research using participatory and action oriented the mental health system. Positive change results
approaches can inspire innovative practice to address gaps when communities are mobilized through increased
and barriers in policy and in practice. dialogue aimed at de-stigmatizing mental illness
and through active exchange with mental health services
Main Messages of the CURA Study to increase knowledge & skills for both sides. Cultural
The Taking Culture Seriously in Community Mental communities optimize their strengths when they
Health study results indicate the importance of a recip- develop ongoing collaboration strategies, validate and
rocal relationship between the mental health system and encourage mental health practitioners from within the
diverse communities. It points out that all stakeholders cultural community itself, and recognize that individ-
involved need to work together differently, so that collabo- uals and organizations that bridge across cultures and
rators are mutually responsible for ensuring power is services contribute to solutions.
shared to optimize mutual benefits. We acknowledge this The Taking Culture Seriously in Community Mental
goal is not easily accomplished, but it becomes more Health results indicate the importance of prevention in
attainable when: mental health. Stigma-busting health promotion, early
Time, space and resources are devoted to collaboration interventions and population specific interventions were
The mental health system is open to change strongly suggested. The importance of ongoing learning
Policies & procedures within the mental health system and exposure to cultural diversity by all players in the
support innovation mental health system is needed along with sustainable
The problem to be addressed is clearly defined funding for innovative practice and accountability by
There is a long term vision and commitment using PAR evaluation research.
Diverse cultural groups, policy makers, & practitioners For more information about the CURA study, see
take leadership in different parts of the solution www.takingcultureseriouslyCURA.ca

63
 Joanna Ochocka, Elin Moorlag, Sarah Marsh, Karolina Korsak, Baldev Mutta, Laura Simich and Amandeep Kaur

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CA: Sage Publications.

64
Improving Mental Health Services
for Immigrant, Refugee, Ethno-
cultural and Racialized Groups
Kwame McKenzie is a Professor of Psychiatry at the University of Toronto and he is the Medical Director of Health Equity at the Centre
for Addiction and Mental Health. He is a psychiatrist, researcher and policy adviser. Dr. McKenzie has authored four books and over
100 academic papers. His policy interests are improving services for immigrant, refugee, ethno-cultural and as a researcher he is the
Director of the Canadian Institutes of Health Research (CIHR) Strategic Training Centre in the social causes of mental illness (SAMI)
and is an expert on cross cultural psychiatry and social capital.
Emily Hansson is a research coordinator at the Centre for Addiction and Mental Health (CAMH). With a M.Sc. in Medical Anthropology.
Her research interests include both international and cultural mental health; in particular, exploring cultural understandings of mental
health and illness. Ms. Hansson has spent time in Southern Africa working in global health and contributed to the Global Health
Watch publication.
Andrew Tuck is a research assistant at the Centre for Addictions and Mental Health. He has an MA in Sociology. His research interests
include self-harm and suicide, victims rights and criminology, and the social determinants of health in relation to IRER groups and
mental health.
Steve Lurie is currently the Executive Director of the Canadian Mental Health Association Toronto Branch, a post he has held since
1979. Has been a Board member and Vice President of the Ontario Federation of Community Mental Health and Addiction Programs
and represented community health employers on the Board of the Health Sector Training and Adjustment Program, where he served as
Treasurer. He served as a trustee on the Board of the Centre for Addiction and Mental Health, (CAMH) from 1998 until 2007. Steve is
adjunct faculty at the University of Toronto Facultys of Social Work and currently chairs the Service Systems Advisory Committee of
the Mental Health Commission of Canada.

abstract
Canada is one of the most diverse countries in the world but its mental health policy and services do not embrace that diversity.
People from immigrant, refugee, ethno-cultural and racialized (IRER) groups often have poorer access to care and poorer treatment.
The size of the population and specific issues may differ in each province or territory but all jurisdictions will have to provide mental
health services to their multi-cultural population, and develop health promotion strategies that improve the health status of IRER
groups. With this in mind, the Service Systems Advisory Committee of the Mental Health Commission of Canada established a project
to consider the issues and options for service improvement for IRER groups in Canada. The emergent issues and options will help the
Commission to develop an equitable Mental Health Strategy for Canada.

Acknowledgements:
We would like to acknowledge the Service Systems Advisory Committee of the Mental Health Commission of Canada, those in the
Diversity Task Group, and those who participated and organized both the in-person and electronic consultations for your invaluable
input. We are also grateful to those involved with the consumer focus groups. This includes those from Across Boundaries and
the Canadian Mental Health Association Toronto Branch who organized and facilitated these groups as well as the participants
of these groups. We gratefully acknowledge the support of the Mental Health Commission of Canada and the Centre for Addiction
and Mental Health.

65
 Kwame McKenzie, Emily Hansson, Andrew Tuck, and Steve Lurie

Introduction a collective there will be particular sub-groups and indi-

Improving services and outcomes for immigrant, viduals to whom the statement does not apply. However,
refugee, ethno-cultural and racialized groups (IRER), is one thing that all IRER groups have in common is that
now a common issue for mental health systems in high they are on average younger than other population groups
income countries (Hansson et al, 2009). Worldwide there in Canada.
are 20 major cities with over half a million residents that The challenges faced by refugees are different
were born in a different country. The Canadian Senate from the challenges for new immigrants and these in
investigated the response of health systems in selected some measure are different from those faced by ethno-
countries, (Australia, New Zealand, the UK and USA) to cultural and racialized groups who have been in Canada
the needs of their diverse populations (Standing Senate for some time.
Committee, 2004). They concluded that there was often The study did not specifically investigate the
poorer access to mental health care and this was associ- diversity within diverse populations because it was
ated with: increased use of crisis and emergency care, considered that separate targeted studies were needed to
increased use of the police and prison justice system, do justice to the issues of service development for
increased hospitalization (involuntary), poorer outcomes, IRER Lesbian, Gay, Bisexual, Transgender, Transsexual,
and an increased community burden of mental illness. Two-spirited, Inter-sexed, Queer, and Questioning
The picture is however complex and dependent on (LGBTTTIQQ) population and age or gender groups.
context. For instance, the reasons for migration in Some of these groups are marginalized within
different groups, the reception of the host population, the already marginalized groups and analysis may indicate
socio-economic position of a group, differences in culture significant increased risk for the development of
and language, and the structure of the health system are mental health problems and illnesses and a need for
just a few of an intersecting array of variables which may service improvement.
be important and make importing ideas and practices
from other countries difficult. Methods
Canada is becoming more diverse each year because The study used a number of different lines of investi-
immigration is the driver of population growth. The size gation and consultation.
of the population, the rate of increase, and specific issues An analysis of the data from the 2006 Census
may differ in each province or territory but all jurisdic- supplemented by available data from different provinces
tions will have to provide mental health services to their was used to produce a statistical picture of Canadas IRER
multi-cultural population, and develop health promotion groups. A literature review of published papers was then
strategies that improve the health status of IRER groups. performed with the guidance of a specialized mental
With this in mind, the Service Systems Advisory health librarian. These two sources of information and the
Committee of the Mental Health Commission of Canada experience and knowledge of a steering group of experts
established a project to consider the issues and options for in multicultural health from across Canada was used to
service improvement for IRER groups in Canada. help develop a paper outlining the issues and some
potential options for service improvement for IRER
Who was considered by the project? groups. Consultation on this paper took a number of
Canada is one of the most diverse countries in the forms. The paper was posted on the Mental Health
world. The study did not attempt to deal with all diverse Commission of Canada website and on the Centre for
groups. It was limited to assessing the mental health Addiction and Mental Healths website. A survey
needs and services for those who are from an immigrant, monkey tool was developed so that the public could give
refugee, ethno-cultural, or racialized group (IRER). their opinions on the paper and more specifically the
It quickly became apparent that there was no one options for service improvement. The electronic postings
term that encompasses all of these categories so the were widely advertised at face-to-face presentations,
acronym was coined. Canadas IRER groups are comprised through professional networks and through community
of different populations with different histories, cultures, networks. The paper was sent to bodies that govern health
social realities and needs. There are some common expe- in provinces, territories and cities, to Federal Government
riences such as issues of status in society and difficulties offices involved in health in general, and in settlement and
with access and use of services but there is substantial and welfare services for immigrants and refugees. Face-to-face
significant diversity. Diversity within groups includes focus groups of professionals, service providers,
different national heritages and cultures as well as social community organizations, and settlement and education
location due to gender, sexual orientation and physical services were undertaken in seven centres across Canada
ability. For every statement where a group is considered as from Vancouver to St. Johns.

66
 Improving Mental Health Services for Immigrant, Refugee, Ethno-cultural and Racialized Groups

Feedback from the face to face and electronic consul- and in the receipt of services (Hansson et al., 2009). Other
tations was incorporated in the paper. studies report that a positive ethnic identity (Fenta et al.,
Because people with lived experience of mental 2004), employment (Beiser et al., 2004) and social
health problems and illnesses were under-represented in networks (Dyck, 2004) decrease the risk of mental illness.
the focus groups, extra focus groups specifically for this The balance of influence of these issues is different
sector of the population were undertaken to ensure that for different groups, for instance: refugee groups are more
the recommendations were in line with the aspirations of likely to be exposed to pre-migration problems, whereas
people who use current services. Finally, there was a poverty and under-employment may be more important
national consensus meeting to review the findings and in recent immigrants (Hansson et al., 2009). Information
recommendations which was attended by a diverse group on existing ethno-cultural and racialized groups is not
including people with lived experience, clinicians, well captured in the census.
academics, policy makers and members of the Mental Rates of mental health problems and illnesses:
Health Commission of Canada. National studies report lower rates of anxiety and depres-
sion in immigrant groups (Ali, 2002). This may reflect
Results true lower levels of illness which is expected because
Census data: The analysis of the Census data offered immigration practices may screen out entry for people
a snapshot of Canadas diversity. Every province, territory with existing physical or mental illness. However, it could
and region has an IRER population; the populations are also be due to concern about getting permanent residency,
all growing but at different rates. The demographic could be inaccuracy in the disclosure of mental health
changes vary with some areas having substantial existing problems and illnesses in official surveys. Studies report
IRER populations that need to be served and others that over time the lower rates of common mental
having small populations that are growing quickly. disorders rise to the level of the general population (Ali,
Within IRER groups there is significant diversity and 2002).
intersecting issues such as older age, youth, sexual prefer- There are significant differences between groups as
ence or gender issues which add a further level of well with specific groups in particular areas reporting
complexity of need when considering service develop- high rates of mental health problems and others reporting
ment. Over 200 different languages are spoken in Canada lower rates (Hansson et al., 2009).
and 20% of Canadians have a non-official language as Barriers to care: Access to care is a major issue.
their mother tongue (Statistics Canada, 2006). Where particular IRER groups have higher or lower rates
Canadian literature: There is growing Canadian of illness is a moot point given they all have difficulty
academic and grey literature investigating IRER mental getting care. Equity of service provision is a particular
health. It focuses on three areas: social determinants, the concern. Canadian literature cites barriers to care such as
rate of mental illness, and barriers to and facilitators of stigma, awareness of services, language difficulties, trans-
care. There have been a few national studies but these are portation costs, socio-economic factors and differences in
not detailed enough to form the basis of service develop- illness models between services and clients as factors that
ment. The research has mainly been undertaken in British delay treatment (Hansson et al., 2009). There are a
Columbia, Ontario and Quebec (Hansson et al., 2009). number of studies which also list factors that have been
Most provinces, territories and regions do not have a local demonstrated to facilitate service use. These include
evidence base to use for developing services. literacy, trust in services, cultural competence, targeted
Social determinants: The literature reports that IRER health promotion, an increased diversity of services, and
groups are more exposed to the known social factors that links between different types of services.
promote mental health problems and illnesses as well as Policy analysis: National responses to these issues
other social factors such as migration, discrimination and have been rare. There has been some consideration of the
language difficulties (Hansson et al., 2009). Those from needs of new immigrants and refugees but this has not led
IRER groups in general are more likely to live in poverty, to significant service development. There has not been a
to be unemployed or underemployed, to be socially similar consideration of the mental health needs of
isolated and to live in neighbourhoods that are disadvan- existing ethno-cultural and racialized groups.
taged (Clarke et al., 2008). In addition, pre-migration
factors (such as war and torture), post migration factors Issues and Options:
(such as acculturation and uncertainty because of the a strategy for service development
immigration system), exposure to racial discrimination The service improvement recommendations that
and difficulties due to language are significant issues in were developed from the data and the consultation have a
the generation of mental health problems and illnesses firm foundation in the goals of the Mental Health Strategy

67
 Kwame McKenzie, Emily Hansson, Andrew Tuck, and Steve Lurie

for Canada. The Strategy will be based on the principle written plans to improve the mental health of IRER
that everyone can benefit from improved mental health groups and services for mental health problems and
and well-being, while also acknowledging that people illnesses. If these are coordinated at the various levels of
living with mental health problems and illnesses will need government and across different sectors then they will be
special services and supports. This includes helping adults more effective. Plans will need data streams and initiatives
recover, children and youth to maximize their mental will need to be evaluated. One approach which brings
wellness as they pass through different developmental many of these actions together would be to develop popu-
stages, seniors to maximize their quality of life and lation-based, flexible services. Provinces, territories and
dignity as they age, and for all people living in Canada to regions would produce a plan to tailor service develop-
achieve greater well-being. ment to their demographic imperatives. The plan would
The Commission is firmly convinced that a focus on focus on policy improvement and public health interven-
recovery, including hope, empowerment, choice, and tions aimed at health promotion and illness prevention as
responsibility, needs to occupy a central place in the well as interventions targeted at service improvement. The
transformation of the mental health system in Canada. exact extent of the plan would depend on the needs of the
The objective will be to ensure that people living with population and, of course the resources available.
mental health problems and illnesses of all ages are The involvement of communities, families and
treated with the same dignity and respect as their fellow people with lived experience is key. Engaging local IRER
citizens and have the opportunity to lead full and mean- population groups in the planning process helps in the
ingful lives in the community, free from discrimination. development of more appropriate services and also allows
However, in order to be comprehensive, the strategy for linkage to community based services, decreasing
will also need to look at ways of keeping people from duplication and increasing the diversity. The planning
becoming mentally ill in the first place and at how to process will also have a community engagement and
improve the mental health of the whole population. The knowledge exchange function that may build capacity and
challenges in this regard are many, but the potential networks, improve awareness and access to care.
benefits are enormous. Mental health promotion and With a plan in place, a data stream and an engaged
illness prevention can both enhance overall mental health community, services can forge a path of collaboration and
and well-being of the population and also contribute to internal development. There are five groups of actions
reducing the individual, social and economic impact of required to improve mental health services for IRER
mental health problems and illnesses. groups:
The study outcomes took the position that the chal- 1. Changed focusan increased emphasis on prevention
lenges faced by IRER populations need a mainstream and promotion
service response. All services will need to be capable of 2. Improvement within servicesorganizational and indi-
offering equitable care to Canadas diverse population. vidual cultural competence
Such a response would need to recognise the extensive 3. Improved diversity of treatmentdiversity of providers,
diversity that exists within these groups. It will also need evaluation of treatment options
to recognise that the direction of travel is towards a 4. Linguistic competenceimproved communication
position where service providers are working alongside plans and actions to meet Canadas diverse needs
groups and communities to improve mental health and 5. Needs linked to expertiseplans to offer support by
where services that are capable of offering equitable people and services with expertise to areas with lower
treatment to Canadas diverse population are a funda- IRER populations so they can offer high quality care
mental building block of the health system. In line with The study included 16 recommendations for service
the Mental Health Strategy for Canada, mental health improvement as well as some examples of how these ideas
promotion and illness prevention are considered as are being implemented in various parts of Canada.
important as service improvement. Neither is exhaustive nor prescriptive. They offer an
The plan for moving towards the vision of improved outline of the issues that planners will have to face when
services for IRER groups has three intertwined actions: moving forwards. Across Canada pockets of good practice
1. Better co-ordination of policy, knowledge and account- exist but to date there is no area whose respondents say
ability; their services are meeting the mental health needs of their
2. The involvement of communities, families, and people IRER populations.
with lived experience; and,
3. More appropriate and improved services. Conclusions
Better coordination of policy, knowledge and The strategies for service improvement outlined in
accountability recognises the need for there to be specific the final report are an attempt to fuse the data, the views

68
 Improving Mental Health Services for Immigrant, Refugee, Ethno-cultural and Racialized Groups

of a diverse group of people with interest in the issues and Dyck, I. (2004). Immigration, place and health: South Asian
those of governance bodies across Canada. It is not a womens accounts of health, illness, and everyday life. Research
on Immigration and Integration in the Metropolis, No. 04-05.
protocol for service development but an outline of the
issues that policy makers, health planners, and service Fenta, H., Hyman, I., & Noh, S. (2004). Determinants of depres-
providers may find beneficial to consider when embarking sion among Ethiopian immigrants and refugees in Toronto. J
on improving mental health services for IRER groups. Nerv.Ment.Dis., 192, 363-372.

Hansson, E., Tuck, A., Lo, T., Lurie, S., Pendakur, S., and
McKenzie, K. (2009). Improving mental health services for
immigrant, refugee, ethno-cultural and racialized groups:
References Issues and options for service improvement. Mental Health
Commission of Canada Diversity Task Group.
Ali, J. (2002). Mental Health of Canadas Immigrants. Supple-
ment to Health Reports, volume 13. Statistics Canada, Standing Senate Committee on Social Affairs, Science and
Catalogue no. 82-003. Technology (2004). Mental Health Policies and Programs in
Selected Countries. 38th Parliament1st Session.
Beiser, M. & Wickrama, K. A. (2004). Trauma, time and mental
health: a study of temporal reintegration and Depressive Statistics Canada (2006). The Evolving Linguistic Portrait.
Disorder among Southeast Asian refugees. Psychol.Med., 34, ht t p://w w w12 .st atca n.gc.ca/eng l ish/cen su s 0 6/a na lysis/
899-910. language/pdf/97-555-XIE2006001.pdf. Accessed August 01,
2009, Catalogue no. 97-555-XIE.
Clarke, D. E., Colantonio, A., Rhodes, A. E., & Escobar, M.
(2008). Pathways to suicidality across ethnic groups in Canadian
adults: the possible role of social stress. Psychol.Med., 38,
419-431.

69
 Mental Health Service Utilization
by Chinese Immigrants:
Barriers and Opportunities
Lin Fang is an Assistant Professor at Factor-Inwentash Faculty of Social Work, University of Toronto. Her research interests include
acculturation, psychosocial adjustment of immigrant families, culturally appropriate mental health assessments and treatments,
and prevention of substance abuse among adolescents.

abstract
Mental health service underutilization by Chinese immigrants is a critical health and equality issue. This article reviews
factors that contribute to low mental health service use across individual, family, cultural and system domains, and
discusses ways to improve the responsiveness and equality of mental health care in Canada for Chinese immigrants.

Immigrants often experience an elevated levels of seen as representing the wrath of supernatural spirits (Gaw
psychological distress in the period soon after immigra- 1993; Kramer et al. 2002; Koss-Chioino 2000) or ancestors
tion (Beiser and Edwards 1994). Job insecurity, altered (Barnes 1998; Lin and Lin 1981) induced by patients or
family dynamics, economic hardships, and cultural differ- other family members. In a Toronto study, Chinese immi-
ences between the country of origin and the host country grants who subscribe to supernatural beliefs tend to hold a
all contribute to heightened psychological stress during negative attitude toward seeking professional help (Fung
the first years following immigration (Ritsner and Poni- and Wong 2007). Traditional medical theory also plays an
zovsky 1999; Tang, Oatley and Toner 2007). Paradoxically, important role, in which all illnesses, both physiological
studies in North America have repeatedly confirmed the and mental, are considered as imbalances of yin and yang
underutilization of formal mental health services by (Lin and Lin 1981; Chung 2002; Ergil, Kramer and Ng
Chinese immigrants (Bui and Takeuchi 1992; Chen and 2002; Ma 1999). Psychosocial factors, such as major life
Kazanjian 2002; Sue and Sue 1999; Tsai, Teng and Sue events, are also considered to contribute to the onset of
1981; Matsuoka, Breaux and Ryujin 1997; Kung 2003). mental illness (Kramer et al. 2002; Lin and Lin 1981).
Studies have documented that by the time Chinese immi- Lastly, genetic transmission and the inheritance of the
grants finally receive formal mental health treatment, consequences of familial misconduct may be considered as
they tend to present more severe symptoms compared to causes of mental illness (Lin and Lin 1981). Each
non-immigrant users (Snowden and Cheung 1990; Chen component described above is weighted differently,
et al. 2003), are harder to treat, and frequently require depending on the individual and context.
lengthy inpatient hospitalization. The second factor affecting Chinese immigrants lack
What may contribute to gaps between mental health of treatment for mental illness is the experience of shame
needs and service utilization among Chinese immigrants? and stigma. Stigma attached to mental illness may prevent
Literature has shown that factors explaining service under- Chinese immigrants and their families from seeking
utilization are multifaceted, extending across individual, mental health services (Chung 2002; Gaw 1993). Although
family, cultural and system domains. The first of these is psychiatric stigma is a well recognized issue across
the cultural explanation of mental illness. Cultural beliefs cultures, it may have more severe and decisive conse-
regarding the cause of mental disorders greatly affect quences among the Chinese (Sue and Sue 1987). The
service utilization. The aetiology of mental illness includes negative effect of stigma among the Chinese is often
moral, religious or cosmological, physiological, psycholog- reflected in a low rate of mental health service utilization,
ical, social and genetic factors. From a moral perspective, excessive concern about confidentiality, reluctance in
mental illness is deemed to be a punishment for miscon- using insurance coverage, and absolute refusal to use
duct against Confucian norms, the principles defining professional help in the face of obvious psychiatric
interpersonal relations and personal behaviours (Kramer et symptoms (Gaw 1993).
al. 2002; Lin and Lin 1981). As implicated in the religious Literature suggests that given the collective and
or cosmological perspective, mental illness has also been family-centered cultural orientation in Chinese society, an

70
 Mental Health Service Utilization by Chinese Immigrants: Barriers and Opportunities

individuals mental illness taints family grace, and naming Lin 1981; Lin and Cheung 1999). Lin and Lin (1978)
and shaming extends to ancestors (Kramer et al. 2002; Lin studied help-seeking patterns among Chinese Canadian
1981). Furthermore, seeking mental health services is not families having a member with psychotic disorders and
only considered to bring shame to the individual, but also identified a hierarchical pattern that has five phases.1
to his family members, their ancestors and their offspring Notably, the first three phases, seen as a protracted intra-
(Gaw 1993; Leong and Lau 2001). Fear of losing face and familial and pre-psychiatric stage, can last from several
being derided is common among Chinese families with to over 20 years. When the family and other informal
mentally ill members. This, in turn, leads to a denial of the networks have failed to provide effective assistance, the
existence of mental illness, or attempts to mask the formal institution is the last resort for a person with
problem with a socially acceptable label. Clearly, family- severe mental illness (e.g. psychotic disorders). Individuals
oriented stigma prevents individuals with mental health with other types of mental illness, such as depression,
needs from receiving timely and appropriate assessment neuroses or psychosomatic diseases, hardly ever approach
and treatment (Gaw 1993; Lin 1981). mental health professionals, since these conditions are not
Symptom presentation also influences the use of mental regarded as mental health problems (Lin and Cheung
health services. Chinese people tend to perceive mental 1999). Kung (2003) studied Chinese adults in the Los
disorders as organic disorders (Lin and Cheung 1999; Uba Angeles and discovered that 75% of respondents who had
1994). Often, Chinese patients express their psychological emotional needs did not seek help from any resource. Out
problems in a psychosomatic form, which can explain why of the 25% who ever sought help, family and friends
somatisation and neurasthenia are commonly observed in appeared to be the major source (20%). Moreover, among
Chinese communities. Somatisation is the presentation of respondents who had a diagnosable mental disorder, only
personal and interpersonal distress in an idiom of physical 15% had used mental health services.
complaints together with a coping pattern of medical help- Effect of discrimination. Facets of social context that
seeking (Kleinman et al. 1986, 51). Consistent with the are ever present in the lives of visible minorities are
Chinese cultural context, somatisation allows one to racism and discrimination. The perceptions of being
suppress the expression of potentially disruptive and ego- treated unfairly or with disrespect due to ones race or
centered experiences in order to maintain the harmony of ethnic background can play a role in the development of
social relations. Transferring the mental disorder to a mistrust of service providers and subsequent reduced
physical complaint also meshes with the desire to avoid the service use among minority populations (Spencer and
strong stigma attached to mental illness. Additionally, soma- Chen 2004; van Ryn and Fu 2003). Spencer and Chen
tisation is consistent with the perceived legitimacy of (2004) have found that discrimination is associated with
seeking help for bodily complaints rather than psychological greater use of informal services and more assistance
issues (Kleinman 1981). sought from friends or relatives, but not with use of
Somatisation also contributes to the popular use of formal services among Chinese Americans. Moreover,
neurasthenia. Originating in the U.S. in the 1860s, neur- discrimination due to speaking a different language or
asthenia was introduced into China in the early 1900s and having an accent was a significant contributor to the types
has been widely accepted and recognized in Chinese of service one may useChinese Americans who have
communities (Kleinman et al. 1986; Lee 1998; Flaskerud experienced language discrimination were 2.2 times more
2007). Neurasthenia is a complaint of increased physical likely to use informal services and 2.4 times more likely to
or mental fatigue that often reduces individual perfor- seek help from friends or relatives compared to those who
mance and functioning (World Health Organization did not experience such a treatment.
1993). It often is accompanied by diverse somatic and The lack of recognition by general practitioners.
psychological symptoms, ranging from headaches, Somatisation or focusing on somatic symptoms of mental
dizziness, fatigue, insomnia, chest discomfort, and gastro- health issues naturally leads Chinese patients to consult
intestinal problems, to depression, anxiety, irritability, their general practitioners, rather than seeking help from
and anorexia. Often, psychological issues are secondary to mental health professionals (Hsu and Folstein 1997).
physical problems (Schwartz 2002). Although neuras- However, Chung and colleagues (2003) has indicated
thenia was eliminated from the U.S. Diagnostic and general practitioners, including those who speak the same
Statistical Manual as of 1980 due to its indiscriminate language and share the culture, often fail to recognize
features, laymen and clinicians in mainland China, Hong and address treat their patients mental health issues.
Kong and Taiwan continue to apply this term (Flaskerud Moreover, the provider stigmawhich refers to physi-
2007; Schwartz 2002). cians fear of embarrassing their patientsfurther
Help-seeking preference is also influenced by Chinese exacerbates negative feelings and inaccurate myths about
culture. Often, family, rather than the individual with mental illnesses, and delays proper referrals and
mental illness, makes the treatment decisions (Lin and treatment for patients who are in need (Chung 2002).

71
 Lin Fang

The use of complementary and alternative medicine health are likely to exacerbate the Chinese clients mental
also influences access to conventional mental heath health condition.
services. Literature suggests that along with traditional Provider education. General practitioners are the
Chinese health beliefs, indigenous medical practices exert gatekeepers to specialists and other medical services. To
important effects on the manifestation of symptoms and enhance practitioners capacity to detect mental health
health behaviours among Chinese patients (Barnes, 1998; problems early and to ensure adequate service provision,
Kleinman et al., 1975, 1978). First, Chinese patients may education and training are necessary to improve practitio-
rely on traditional Chinese medical practitioners, such as ners skills and knowledge in identifying and treating
herbalists or acupuncturists for relief from emotional mental health problems commonly seen in general
difficulties (Barnes 1998; Lin and Cheung 1999). In practice settings. In addition, providers should learn how
addition, as indicated earlier, the folk concept that mental to communicate with patients about using culturally
illness is caused by supernatural forces and ancestral appropriate and familiar wordings, describe the biopsy-
deeds is widely accepted in Chinese society. Therefore, chosocial basis for mental illness, and discuss possible
folk healers such as shamans, physiognomers, treatment plans.
geomancers, bonesetters and fortune-tellers are also Workforce development. Increasing the representa-
commonly used in helping the Chinese manage daily tion of bilingual and bicultural staff is critical in
stresses and treat illnesses (Gaw 1993). In Kungs study addressing the service utilization issue. Efforts should be
(2003), 8% of Chinese respondents with emotional made to attract and recruit bilingual and bicultural indi-
problems reported that they had sought help from herbal- viduals to disciplines that are related to mental health
ists, acupuncturists, religious leaders or fortune-tellers. service, such as nursing, medicine, psychology, and social
Compared to obtaining assistance from mental health work. Moreover, interpreter services should be made
clinicians or medical doctors, these alternative accessible at practices where bilingual service is not
approaches are more likely to be solicited. available. Providing culturally and linguistically appro-
A lack of accessibility to linguistically and culturally priate services not only tackles the availability and
appropriate mental health services has been proposed as accessibility issue, but also can address the negative effect
one of the major reasons for service underutilization in of language discrimination on service utilization among
this population. Perceived access to services was the most Chinese immigrants.
significant factor predicting negative attitudes towards Community outreach and education. Community
seeking professional help among Canadian immigrants outreach and education are necessary means to raise the
from mainland China and Taiwan (Fung and Wong 2007). awareness of mental health issues and to overcome the
Lin (1994) studied the length of treatment and dropout stereotypes of mental health problems among Chinese
rate of 145 Chinese Americans treated by ethnic- and immigrants. Linguistically and culturally appropriate
language- matched clinicians in an outpatient clinic and information related to mental health can be disseminated
concluded that providing well-trained and culturally to members of the Chinese community through the use of
matched providers promotes the acceptance of mental educational brochures, mass media, health fairs, or
health treatments among Chinese Americans and helps to community workshops.
ensure equal access and treatment opportunities. Working with families. Family can exert a strong
influence on a Chinese patients healthcare decisions.
Overcoming Barriers Practitioners should not underestimate the pronounced
As is true for other ethnic groups, mental influence of family on the lives of individuals with mental
health service utilization among Chinese immigrants is health problems (Kung, 2001; Uba, 1994), and should seek
multidimensional and complex. Efforts ranging from to understand the help-seeking patterns from the family-
micro- to macro- levels are needed to address the under- oriented perspective in addition to individual-focused
utilization issue: assessment. Furthermore, practitioners should strive to
Assessment. Understanding the interconnections engage the family members into help-seeking processes
between mind, body, and spirit is essential for service through harnessing the potential barriers resulting from a
providers and it will allow practitioners to provide more poor communication between providers and patient
relevant, effective and efficient services. When assessing system. As each family has its idiosyncratic help-seeking
and treating Chinese immigrants, practitioners should and decision-making patterns; the trusting and respectful
be watchful for clients somatic complaints. As studies relationship among patient, family members and
have repeatedly demonstrated, unexplained somatic providers are likely to foster and maximize the treatment
symptoms among Chinese patients may be a manifesta- outcome.
tion of mental health issues (Lin and Cheung 1999; Chung Program development. Mental health needs and
2002; Kleinman et al. 1986). Distresses of physical service use are influenced by socio-cultural determi-

72
 Mental Health Service Utilization by Chinese Immigrants: Barriers and Opportunities

nants. Policy and program makers should provide References

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Kung, W.W. Chinese Americans Help Seeking for Emotional Tsai, M., L. Teng, and S. Sue. Mental Health Status of Chinese
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Services Research, 3(2001): 201-214. Public Health and Human Service Providers Contribute to
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Lin, T., and M. Lin. Service Delivery Issues in Asian-North footnotes

American Communities, American Journal of Psychiatry,
135(1978): 454-456. 1
Phase 1. Exclusive intrafamilial coping. At this stage, all
possible remedial resources and means within the family are
---. 1981. Love, Denial and Rejection: Responses of Chinese used by the family to influence the abnormal behaviour of the
Families to Mental Illness, in A. Kleiman and T.Y. Lin (eds.), sick member to its limit of tolerance.
Normal and Abnormal Behavior in Chinese Culture. city: D.
Reidel, 387-401. Phase 2. Inclusion of certain trusted outsiders in the intrafa-
Ma, G.X. Between Two Worlds: The Use of Traditional and milial attempt at coping, such as friends and elders in the
Western Health Services by Chinese Immigrants, Journal of community.
Community Health, 24(1999): 421-437.
Phase 3. Consultation with outside helpers, such as herbalists,
Matsuoka, J.K., C. Breaux, and D.H. Ryujin. National Utiliza- religious healers, physicians and finally a psychiatrist while
tion of Mental Health Services by Asian Americans/Pacific keeping the patient at home.
Islanders, Journal of Community Psychology, 25(1997): 141-145.
Phase 4. Labelling of mental illness and seeking the psychi-
Mulkins, A., M. Verhoef, J. Eng, B. Findlay, and D. Ramsum. atric service first on an outpatient basis, and then
Evaluation of the Tzu Chi Institute for Complementary and hospitalization.
Alternative Medicines Integrative Care Program, The Journal
of Alternative and Complementary Medicine, 9(2003): 585-592. Phase 5. Scapegoating and rejection, while the sick family
member is kept in a distant mental hospital.
Ritsner, M., and A. Ponizovsky. Psychological Distress through
Immigration: The Two-Phase Temporal Pattern?, International
Journal of Social Psychiatry, 45(1999): 125-139.

74
How Cultural Awareness Works
Miu Chung Yan is an associate professor of the School of Social Work, the University of British Columbia, the Acting Co-Director and a
Domain Leader of Metropolis British Columbia. His research interests include youth from immigrant family, immigrant settlement and
integration at the neighbourhood-level, and critical social work practice with multicultural/racial groups.

abstract
Working with multicultural groups poses routine challenges for many mental health professionals in Canada. This article reports on a
study of 30 frontline social workers and how they reflect on their own cultures when working cross-culturally. The strategies used are
identified and analyzed.

INTRODUCTION The encompassing nature of culture is particularly

Working with a culturally diverse population is an demonstrated when many of the participants move their
everyday reality for many helping professionals in the definition of culture beyond ethnicity and race. As
Canadian mental health field. To negotiate the ingrained indicated in the lived experiences of these participants,
effect of their own culture and to respect their clients the complexity of these concepts is manifested as inter-
cultural differences, culturally competent helping profes- mingled sets of characteristics of their cultural
sionals are expected to maintain a high level of cultural background. As the interview process revealed, most of
awareness, which means a self-awareness of their own the participants identified themselves in a way that
cultural background. In the literature related to many conflated culture, ethnicity, and race (Yan, 2008b).
helping professions, the discussion on cultural awareness The cultural identity of each of these 30 participants
tends to simplify the relationship between the helping is complex. First, the majority of them tended to identify
professionals and their own cultures to a mere filtering as a hyphenated ethno-cultural identity, such as Portu-
process through which the influence of their cultures can guese-Canadian, which carries a set of different ethnic
be controlled, or even blocked, from affecting their cultures. This hyphenated identity is also intertwined
engagement with clients from different cultures. Through with their own personal experiences, such as being an
pre- and post-intervention self-reflection, helping profes- immigrant or being member of a marginalized group.
sionals are assumed to have the ability to sustain their Furthermore, their role as professionals working in a
professional objectivity by restraining their own cultural public institution also required them to be reflective on
influences when they engage in a professional relationship the professional and socio-organizational cultures that
with clients from different cultures. However, this are in tension with both their own and their clients
assumption has seldom been examined empirically. Based cultures (Yan, 2008a). In a nutshell, the cultures on which
on the findings of an exploratory qualitative study, this these participants need to reflect are never monolithic
article reports how 30 social workers in the Metropolitan and simple.
Toronto area, different in terms of gender, age, ethno- Most participants reported that they constantly
racial identity, length of time practicing social work, engage in self-awareness when they work with culturally
nature of practice, and service settings, engaged in diverse clients in order to avoid bringing their biases into
cultural awareness in the practice as social workers. Since the helping process. Simply put, to almost all of the partici-
social work is a key helping profession in the mental pants, awareness of their own cultures augments their
health field, findings of this study may shed light on how professional competence to maintain a balance between
other helping professionals engage in cultural awareness preserving a non-judgmental attitude and presenting them-
when working with a culturally diverse population. selves as passionate human beings. However, the
all-encompassing nature of culture prompts some people to
FINDINGS suggest that culture to humans is like water to fish; people
Most of the participants in this study understood do not and cannot exist outside of their cultural contexts.
culture as a totalized and encompassing entity that Very often we live within our culture without knowing its
includes ways of life, ways of coping, beliefs, values, existence and influence. Then, the question is, what triggers
norms, practice, rites, customs and traditions, religion, the professionals reflection? The findings of this study
expectations of others, language, and food and dress. strongly suggest that the presence of clients is the most

75
 Miu Chung Yan

important factor. The cultural similarities or differences 3. Switching Hats

between the workers and their clients, as indicated in this Having a multiple cultural identity, many of the
study, are the major contextual variables that influence the participants report that they are wearing more than one
workers reflection on their own cultures. cultural hat to work. At work, they have to switch their
The findings of this study indicate that reflection is non-professional cultural hat to their professional one by
not simply a retrospection about what they did but also a endorsing the culture embedded in this identity. In the
strategic action of helping. At least two sets of strategic meantime, by switching hats, their own cultures and
actions can be identified conceptually from the findings; experiences are contained, if not at home, at least during
these two sets are not mutually exclusive, and the choice the moment of working with a client. To many partici-
of strategies may not be a conscious act. pants, this may be necessary to maintain the balance
between the professional and personal selves. As a
Controlling Cultures Chilean-Canadian worker employed in a hospital
To control the influence of their cultures on their observes, Well, I think every social worker has to, at one
work which is a relatively common reaction when working level or another, separate them[selves] professionally. And
with clients from a different cultural background, these personally we will hear a story and get pissed off.
participants try to withhold the influences of their non-
professional cultural identities and the sets of cultures 4. Selective Presentation of Self
and experiences attached to these identities. The partici- Most participants tend to think that with experience
pants presented at least six ways of controlling their and good skills, they can be competent social workers who
cultural influences. transcend cultural barriers. They also believe that, from a
clients perspective, whether a worker is competent
1. Detaching Oneself from Ones Own Culture depends on how well he/she can help the client. Therefore,
To be professional, many participants have to detach selectively presenting themselves as competent helpers to
their ethnic/racial identity from their professional role, their clients becomes a major way to control their cultural
sometimes even when their ethnic/racial identity is under image. As an Iranian-Canadian working in a mental
attack. In fact, unlike the Caucasian participants, most of health clinic reported, I certainly try to project myself as a
the racial minority participants have experienced being person who is professional about my job. I am maintaining
rejected by their Caucasian clients. Surprisingly, almost appropriate boundaries. [I am] somebody who is
none of them reported being involved in any direct competent, reliable thats how I want them to see me.
confrontation as a result of these kinds of racial attacks.
Instead, several visible minority participants reported 5. Assuming the White Identity
that, on hearing their clients criticize people from the Regardless of their ethno-racial background, partici-
participants own racial/ethnic background, they tried to pants of this study tend to point out, one way or another,
detach themselves from the clients racist criticism, or like that the Whiteness imagethat of a mainstream
one participant noted, So when I hear this thing, I will be workeris perceived as the standard by which they (and
very conscious to separate this, [as this] is a client talking their clients) measure their level of competence. This
about his or her experience, it is not about you although sense of Whiteness, according to many participants, is
this is a situation that requires challenging. embedded in their training, their practice setting, and the
nature of the profession. Therefore, to be seen as
2. Separate Life Domains competent in this profession, even minority workers must,
Many participants try to keep their work and insofar as it is possible, take on a White identity. Linda,
non-work life domains separated, especially when they are a Chinese-Canadian who works in a childrens mental
not fully coherent with each other. Most minority partici- health agency, explains her reasons for assuming this
pants are eager to keep their cultural roots at home while White identity:
they try to adapt to the dominant culture at work. The For me, as a minority therapist, I face
underlying assumption of separating life domains is double challenges. When I work with
literally that culture can be controlled. As a Black social minority people, I have my counter-
worker in Childrens Aid stated, Work might be a little transference towards them too because I
different from home because home tends to be more am also a minority. I also dont want
typical. The home culture, that is your own home. but them to see me as powerless, weak. To be
coming to work, I leave a little bit at home and take more seen as small, weak and helpless, right?
of the Canadian norms to work. Yes, so its partly different. So there is a counter-transference part
I might do things at home that I might not do at the office. from my position. When I see White

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 How Cultural Awareness Works

people, I will identify with the 2. Therapeutic Self-disclosure

aggressor, so I would want to join them. Self-disclosure is another technique through which
And I think I also want to prove to my participants used personal experience to assist clients.
colleagues, I can do the same work as Most minority participants reported that clients are espe-
them. Its not a conscious choice, though. cially interested in asking them questions related to their
cultural identities in order to verify whether the workers
6. Retrospection are capable of helping them. In a workers cross-cultural
Despite all the strategies that the participants used engagement with a client, disclosing some parts of the
to control or restrain their culture from intervening in workers personal experience and culture is useful for
their work, cultures and experiences may still slip into helping the clients. These participants disclose their own
their interactions with clients without prompting the cultural information in order to make a connection with,
workers to engage the self-awareness mechanism. For empower, and gain trust from their clients. Nevertheless,
instance, a Chilean-Canadian working in a hospital not all of the social workers culture and personal experi-
remembered a time that she was unconsciously critical of ence is subject to disclosure. To many participants,
a daughter who intended to abandon her mother, a patient disclosing is a purposeful and selective strategy. A
in her hospital. In the workers own non-professional boundary needs to be set between what can and cannot be
cultural practice, such abandonment by a daughter was shared. As one participant observed, Is it for the benefit
unacceptable. Instead of becoming cognizant of her for yourself? Is it for the benefit of your client? Be really
feelings at the time, however, and consequently working mindful about when you use self-disclosure within your
to control or contain these feelings, she condemned the therapy. I think about that often and how that relates to
daughter for her intentions. In cross-cultural social work boundar[ies].
literature, retrospection, a form of anecdotal self-aware-
ness, is an expected practice for social workers. By 3. Bridging Clients to the Dominant Culture
deliberate retrospection through recording, peer consul- Many minority participants, particularly those who
tation, and clinical supervision, social workers will try to have been immigrants, will use their cultural and experi-
catch those cultural influences that escaped into their ential knowledge to help their clients adapt to a new
practice. Remedies will be sought afterward. culture they themselves have successfully acclimated to. A
newcomer from Africa working in child protection
Using Cultures services offered a vivid illustration of how he helped an
According to the findings of this study, in addition to African family who had struggled with the child protec-
controlling or containing their cultures, almost all partic- tion agency for a few years to reclaim their child. By using
ipants consciously and purposefully use their own his own experience, he taught them how to understand
cultures and experiences as means of helping clients, and adjust to the cultural expectations of the dominant
especially those who share similar cultural backgrounds society. In this way, social workers who use their own
or experiences with them. In general, three major strate- stories to bridge clients to a new culture also become
gies of using cultures can be identified. agents of social integration.

1. Empathetic Understanding Based on Similarity DISCUSSION

Workers can often build a more effective working rela- These findings show that cultural awareness occurs
tionship through an empathetic understanding with clients before, during, and after the intervention, and that social
who share similar cultures and experiences. Based on workers may engage with their cultures in multiple ways
cultural or experiential similarities, many participants felt as a strategy of helping. Blocking ones own culture, the
that they may have an added intimate dimension in inter- course most often proposed by the literature, involves a
acting with their clients. For instance, many Caucasian series of strategic actions. The findings also indicate
participants always referred to their traveling experience that these 30 social workers, and perhaps other helping
when trying to understand clients from countries which professionals, have been strategically utilizing their own
they visited. Sharing similar immigration experiences, as cultures and experiences as a part of the cultural
many participants have been immigrants themselves, allows awareness process. This strategic use of ones own culture
them to establish special rapport with immigrant clients. challenges the conventional assumption that cultures are
Many participants felt that having a similar cultural and always biased and therefore need to be contained. Using
experiential background to their clients helped them to go ones culture in a professional capacity creates possibilities
to a deeper level to understand clients problems and thus that allow for a more creative and proactive approach to
establish a closer relationship with them. working with culturally different clients. This study helps

77
 Miu Chung Yan

to confirm that many social workers and other helping References

professionals categorize being culturally aware as a
responsible professional act that facilitates effective Yan, M. C. (2008a). Exploring cultural tensions in cross-cultural
social work practice. Social Work, 53(4), 307-316.
service for culturally different clients.
However, the findings also raise some issues that Yan, M. C. (2008b). Exploring the meaning of crossing and
need further study and discussion. The conflation of culture: An empirical understanding from practitioners
culture, race, and ethnicity has distracted attention away everyday experience. Families in Society, 89(2), 282-292.
from some structural problems in the helping relationship
Yan, M. C., & Wong, Y. L. R. (2005). Rethinking self-awareness
and process. The inseparableness of culture, ethnicity, and
in cultural competence: Towards a dialogic self in cross-cultural
race in their stories, their detachment from their own
social work. Families in Society, 86(2), 181-188.
ethno-racial identity even as their clients attack people of
that identity, and their justification for being rejected by
Caucasian clients, to name but a few examples, demon-
strate that many of these participants try to avoid footnotes
challenging the racially oppressive conditions in which
they and their clients are located. Even with an active and This article is an abbreviated version of a published manuscript.
For a full version of this paper, please refer to Yan, M. C. (2005).
strategic reflection on their cultures, without critically
How cultural awareness works: An empirical examination of the
examining Whiteness as a measure of professional interaction between social workers and their clients. Canadian
competence, many visible minority social workers and Social Work Review, 22(1), 5-29.
clients are still struggling to fit in a culturally biased
mode of helping.
This study affirms that cultural awareness is an
interactive, selective, and contingent process. Perhaps the
key to meaningful cultural awareness is the dialogical
understanding of oneself (Yan & Wong, 2005). As noted
in this study, this dialogical process is affected by the
similarities and differences between the workers and their
clients, which are not only cultural but also structural, in
terms of their social positions (e.g., race, gender, and class)
and the context in which the workers and their clients are
located. Social workers therefore need to reflexively reflect
not only on their cultures but also on the invisible privi-
leges embedded in their social positions. Finally, this
study offers only a preliminary understanding of how
some social workers practice cultural awareness. To better
understand this complex process and its significance in
social work practice, more studies are needed.

78
Development of a Culturally
Sensitive Screening Tool:
Policy and Research Implications1
Shahlo Mustafaeva is an international student from Uzbekistan currently pursuing her degree in Clinical Psychology
at the University of Regina.
Regan Shercliffe is an Associate Professor of psychology at the Luther College, University of Regina.

abstract
During the past two decades, Canada has received a large influx of refugees from Asian countries (Noh, Speechley, Kaspar, and Wu,
1992). Upon arrival, refugees are offered health screenings, specifically for communicable diseases, such as tuberculosis, Hepatitis B
and for general pre-existing medical problems. Unfortunately, the same attention is rarely given to potential mental health needs.
Research has shown that the refugees are at high risk for developing depression compared to non-refugee populations, yet they are not
screened. The purpose of this article is to outline the process of developing culturally sensitive depression screenings tools for Karen
refugees. The need and implications of this measure are further discussed.

Introduction refugee population (Carlson and Rosser-Hogan, 1991). The

Depression is one of the leading mental health purpose of this article is to outline the development of a
problems facing individuals in all demographic and ethnic culturally sensitive screening tool and it proposes that
groups (Baker and Woods, 2001). The symptoms of this culturally sensitive screening tool can be developed
depression are psychiatric (e.g., anxiety/nervousness and and used in understudied, culturally distinct refugee
reduced concentration), behavioural (e.g., social with- populations, and that such use will help health care
drawal and crying spells), and physical (e.g., pain, professionals in identifying depression in immigrant
headaches, and insomnia). Over time, many of the populations.
symptoms of depression can become debilitating in
nature and impact both the patients medical treatment Depression as a Global Problem
and workplace productivity (Greenberg et al., 2003). Epidemiological studies have identified depression
Psychiatric and physical impairments associated with as the most prevalent disorder in refugee populations
depression generate a significant cost burden not only for and one of the ten leading causes of disability worldwide
sufferers, but also for their employers, third-party payers, (Steel, Silove, Phan, and Bauman, 2002; Mollica et al.,
caregivers, and society in general. Depression is associated 2004). The process of displacement has a tremendous
with a loss of personal productivity, diminished quality of impact on the health, social and cultural well-being of
life, poor psychological adjustment, reduced income, high refugees, as well as host countries. Upon the arrival of
health care utilization, and a markedly increased risk for refugees, health care agencies focus their attention on
suicide (Katon et al., 1986). In 1990, the economic burden meeting basic needs such as controlling infectious
of depression in the United States alone was estimated diseases and other health conditions. Although this
between $43.7 billion and $52.9 billion, based on the cost focus is crucial, the psychological well-being of newly
of depression treatment, lost earnings due to suicides, and arrived refugees is often neglected. All too often
workplace absenteeism (Greenberg et al., 1993; 1996). refugees who have come to Canada have experienced or
During the past two decades, Canada has received a large witnessed traumatic events including war, forced
influx of refugees from Asian countries (Noh, Speechley, displacement, famine, etc (Arcel, 1995; Lipson and
Kaspar, and Wu, 1992). Given this population trend the Omidian, 1995). In the country of resettlement, refugees
economic burden of depression may have increased from continue to face a number of stressors such as financial
that of the 1990s as the prevalence rates of depression in difficulties, broken extended families, loss of family
refuge population is higher compared to that of non- support, cultural and linguistic isolation, and/or

79
 Shahlo Mustafaeva and Regan Shercliffe

struggles to learn a new language and culture (Lipson easily translated and understood across cultures, subjec-
and Omidian, 1997; Hauff and Vaglum, 1995). While tive psychological aspects of depression (e.g., feeling sad,
many refugees are resilient, these various pre- and post- feeling blue, depressed) are much more influenced by
migration stressors put refugees at high risk of culture and language and vary across cultures (Ghubash,
developing depression, as such, accurate screening of Daradkeh, Naseri, Bloushi, and Daheri, 2000). Thus, the
depression early in the immigration process is urgently application of these instruments to people whose culture
needed for detection and treatment purposes. differs from the population on which they were initially
developed and validated could lead to erroneous conclu-
Challenges in Primary Health Care Settings sions and misdiagnosis (Kazarian and Evans, 1998).
Depression is one of the most common mental Culturally sensitive approaches in screening refugees play
health problems seen in the general medical setting. an essential role in planning services and prevention
Although increasing attention has been paid to depression strategies. Depression is a universal mental health
in the research on the general population; public health phenomenon that is amenable to treatment once
efforts in screening for depression in refugee populations diagnosed (Westermeyer, 1991; Weissman et al., 1996). If
still lags behind. Refugees are more likely to seek care undetected and untreated, however, depression can
from general health practitioners than from mental health become a debilitating problem for any person of any age
providers because it is less stigmatising. In addition, and ethnic group.
refugees, especially from Asian cultures, present with
somatic symptoms (e.g., physical pain, headaches, Developing a Culturally Sensitive Screening Tool
weakness in the body etc) when expressing depression Cultural sensitivity in assessing mental health
which puts them at risk of being misdiagnosed or treated problems and the development of effective psychological
with inappropriate medications for extended periods of interventions requires an understanding of the ways in
time. Some health care agencies use readily available which people in particular cultures articulate the ways
depression measures that are derived from Western they have been affected by adverse life events (Rogler,
definitions of depression, and these measures are trans- 1999; Summerfield, 1999). Familiarity with culturally
lated for use with different refugee populations. The use specific idioms or expressions of distress allows health
of translated depression measures with refugee groups care practitioners to communicate effectively with
is an understandable starting point. However, many distressed community members and to develop mental
researchers suggest that the application of existing instru- health interventions that are likely to be perceived as
ments to the assessment of depression in ethnic responsive to local beliefs and values (Summerfield, 1999).
minorities may not only misrepresent the illness they Culture affects aspects of the illness such as the way
suffer from but may also mislead prevention and symptoms are described and it also affects the experience
treatment efforts (e.g., Kim, 2002; Phan, Steel, and Silove, of illness. Thus, symptoms associated with depression
2004; Miller et al., 2006; Okello and Ekbald, 2006). A may vary from culture to culture and some symptoms
strict reliance on the Western understanding of depres- may be more prevalent in one culture than in another
sion risks inappropriately prioritising psychiatric (Levek 1991; Suleiman, Bhugra, and Silva, 2001).
syndromes that are familiar to Western health care Therefore, for accurate diagnosis and treatment, health
professionals, but may lack meaning to non-Western care professionals should first identify and attempt to
populations for whom local expressions and idioms of understand cultural expressions, symptoms, and under-
distress are more salient (Miller et al., 2006). standings of depression.
Although depression-screening instruments have
been validated and extensively studied in Western Needs Assessment
countries and various translating methodologies have The Regina Community Clinic, who screens all
been employed to enhance the linguistic equivalence of refugees in Regina, has indicated that symptoms of
measures, their translation and use with other cultures is depression among Karen refugee groups are high,
not nearly as simple as it might appear (Ahmad, however, accurate diagnosis is difficult. The physicians
Kernohan, and Baker, 1989; Bravo, Canino, Rubio-Stipec, report that Karen refugees often present with many
and Woodbury-Farina, 1991; Bravo, Woodbury-Farina, somatic complaints such as headaches, body aches,
Canino, and Rubio-Stipec, 1993). Symptom terms often weakness in the body, heart problem or heart disease;
sound awkward or incomprehensible when translated, but the medical tests administered fail to find any
even if the wording is semantically correct (Yeung et al., physical pathology. The misdiagnoses and related treat-
2002). Although terms that address biologically-based ments of the somatic symptoms then generate
symptoms (e.g., fatigue, insomnia, appetite) can be more considerable health care expenditures in terms of clinic

80
 Development of a Culturally Sensitive Screening Tool: Policy and Research Implications

visits, laboratory testing, medication prescribing, test The purpose of using this story was to ascertain the
ordering, and other medical costs, and result in perception of depression from Karen refugee men and
preventing the initiation of timely and appropriate women. Specifically, we wanted to gather information
treatment for depression. The reality is that there is still a from the focus group participants (1) whether the
paucity of culturally appropriate screening tools that can individual in the vignette has a problem/illness; (2) what
help health care professionals screen for depressed and are the symptoms this illness/problem; (3) what other
non-depressed refugees, and this is most certainly the terms and expressions one would use to describe the
case for Karen refugees. Moreover, there are no data illness/problem; (4) the causes of this illness/problem; (5)
available indicating the extent to which symptoms of who the person in the story should seek help from:
depression are present in this particular population nor mental health professional, general practitioner, or
has a system been developed to allow systematic somebody in the community; (6) stigma associated with
screening/monitoring of this refugee group. As a result, mental health issues.
there are no specific reports of mental health needs
among Karen refugees. Implications
Given the absence of culturally sensitive screening The results of this project assisted us in identifying
tools, the exact rate of depression in this population is the ways in which Karen refugees express depression, the
unknown. The Karen community is one of the largest symptoms they associate with depression, their help-
refugee groups in Saskatchewan and has been exposed to seeking behaviour, and the stigma associated with mental
traumatic events prior to their arrival to Canada. Thus, it health issues. More importantly, based on the results of
is important to address their mental health needs in a this project we were able to develop a culturally-sensitive
culturally-appropriate manner. screening instrument for use with Karen refugees in
screening for depression. Early and accurate detection of
Development of Karen Depression Tool depression in this population will improve Karen refugees
In order to address this issue of a lack of appropriate well-being by providing timely and appropriate interven-
assessments and to develop a culturally sensitive tions. This project, and the screening tools developed
screening tool for depression, the authors conducted a from it, offers health care professionals a reliable and valid
project which investigated understandings of depression tool that will help them identify Karen men and women
among a number of Karen men and women. Karen who are depressed. The second phase of this project,
refugees participated in focus group discussions designed where the screening tool was implemented, proved the
to explain how this particular population understands Karen Depression Screening tool to be more accurate in
and deals with the symptoms commonly regarded as detecting depressed patients than a widely used Western
depression. Participants were presented with a short measure of depression (i.e., Center for Epidemiologic
story derived from the works of Wig et al (1980) and Studies Depression Scale).
Karasz (2005) describing individuals emotional and The accurate differentiation of depressed and non-
somatic symptoms of depression. The story was used depressed patients is important in the Karen population
as a means of portraying depression without using as they are inclined to present with somatic symptoms to
technical language. their primary care physicians which then lead to misdi-
For the past two weeks Sara/Nick had agnosis when the physician is not aware of Karen
felt that something was wrong with her/ cultural expressions of depression. Thus, our findings
him. S/he complained of different indicate it is crucial that the health care professionals
troubles at different times; troubles such use the Karen Depression Screening tool to screen them
as headaches, pains in the stomach, for depression first before a costly search for unlikely
general weakness of the body, difficulty diseases and unnecessary treatments. Early detection
breathing and tiredness. S/he couldnt do and treatment of depression will greatly assist the settle-
her/his work as well as s/he usually ment process of refugees, will support strained family
could. Often during the day her/his eyes and community relationships, and in the long term
filled with tears, and she/he felt intense provide real cost benefits and improved health outcomes
sadness. Her/his close friends and for the Karen population. Identification of culturally
relatives couldnt cheer her/him up. S/he distinctive features of depression will also help to pave
found it difficult to fall asleep and s/he the way for sensitive clinical inquiry and the effective
lost her/his appetite (Wig et al., 1980; delivery of therapy for the Karen population. Being
Karasz, 2005). aware of culture-specific symptoms of depression among
Karennis can assist clinicians in minimizing misunder-

81
 Shahlo Mustafaeva and Regan Shercliffe

standings of depressive symptom expression, in References

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meaningful patterns and important cultural differences
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loss of/separation from loved ones that can increase the B., A., & Al Daheri, A., M. The performance of the Center for
Epidemiologic Study Depression Scale (CES-D) in an Arab
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face numerous challenges as they settle and integrate into 46 (2000): 241-249.
the mainstream society. Early and accurate detection of
mental health problems will improve the well-being of new Greenberg, P. E., Stiglin, L. E., Finklstein S. N. et al. The
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MacArthur, J. R., Dudley, S., Williams, H. Approaches to facili- footnotes

tating health care acceptance: a case example from Karenni
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This project was supported by funds from the Regina
tion. Community Clinic, Regina QuAppelle Health Region, and the
Prairie Metropolis Center.
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Mental health in complex emergencies. The Lancet 364 (2004):
2058-2067.

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among Korean immigrants: assessment of a translation of the
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depression in a community sample in Dubai. Transcultural
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111-126.

83
 In the Interest of Working
with Survivors of War,
Torture and Organized Violence:
Lessons from a University/
Community Research Collaborative
in South-Western Ontario
Ginette Lafrenire is an associate professor at the Faculty of Social Work at Wilfrid Laurier University and is the Director
of the Social Innovation Research Group.
Lamine Diallo is an associate professor at Laurier Brantford and the Co-Chair of the Tchepo Institute which is a research
institute dedicated to the study of contemporary Africa.

abstract
This article examines the highlights of an exhaustive research and training project entitled Project Access. Researchers from
Wilfrid Laurier University and a Francophone community health centre (CHC) in Hamilton, Ontario (Centre de sant communautaire
de Hamilton/Niagara) came together to understand how the CHC could best respond to members of various cultural communities who
were survivors of war, torture and organized violence. The research discovered the need for organizations to adapt their services in
ways which were responsive to the particular needs of the survivors. These needs and approaches to mental health care for those
who are survivors of war, torture and organized violence are examined.

Introduction nurturing physical environments for clients as well as

In 2005, an exciting university/community collabora- having diverse human resources who were regularly
tive unfolded between researchers at Wilfrid Laurier exposed to continuing education and training were
University and a Francophone community health centre important themes which emerged within the research.
(CHC) in Hamilton, Ontario (Centre de sant communau- Attention to issues relative to spirituality or religiosity also
taire de Hamilton/Niagara). For approximately eighteen emerged as an important determining factor enhancing
months (18) an exhaustive research and training project the quality of the helping relationship with survivors.
entitled Project Access was engaged in order to under-
stand how the CHC could best respond to members of Francophone Immigration in Hamilton
various cultural communities who were survivors of war, One of the determining characteristics of immigra-
torture and organized violence. The basis of the research tion patterns in Hamilton/Niagara is the increasing
was to unearth certain elements of best practices which number of Francophone immigrants and refugees moving
could enhance the skills of health care and social service into this geographic area. Among these newcomers, the
professionals working with this particularly vulnerable majority are coming from Francophone African countries
target group. What the research discovered was the need influenced by war and political upheaval. According to the
for organizations to adapt their services in ways which CHC, there are an overwhelming number of people from
were responsive to the particular needs of the survivors. the Congo, Tchad, Rwanda, Central Africa, Burundi,
Demystifying the importance of mental health services for Guine and the Ivory Coast coming to Hamilton or are on
survivors was an especially challenging element which their second migration from Quebec. The arrival of these
characterized the work of providers. Additionally, creating New Franco-Ontarians has pushed health and social

84
 In the Interest of Working with Survivors of War, Torture and Organized Violence:
Lessons from a University/Community Research Collaborative in South-Western Ontario

services to adapt to this particular clientele which very which informed this project and as such monthly
often is unilingual Francophone and grappling with the meetings were organized between the research team
after effects of war and torture while attempting to and representatives of the CHC through an advisory
integrate within an Anglophone, mainstream environ- committee. The research team met several times with
ment. As a result of witnessing the enormous difficulties staff and key informants and two community forums
that many of the stakeholders within these various were held in both Welland and Hamilton in order to
cultural communities experience relative to the integra- get feedback and share the data collected from all
tion process, the CHC in Hamilton decided to undertake research stakeholders;
an ambitious project in order to best respond the needs of Five all day training sessions were offered approximately
this particular clientele. The leadership of the CHC every four months during the life of the project and were
successfully applied for funding to the Ministry of Health dedicated to enhancing the skills of the staff of the CHC
and hence Project Access emerged. on the following subjects: organizational change in the
face of diversity, how to intervene with survivors of
Objectives of Project Access trauma, working with survivors of sexual torture, work-
In 2004, the CHC witnessed an increasing number of ing with survivors of female genital mutilation (FGM),
clients from Francophone cultural communities who and models of intervention from five Canadian agencies;
seemed to be presenting with an array of issues which A short documentary informed by survivors as well as
characterized them as being somewhat more vulnerable health care and social service professionals was devel-
than many other clients of the CHC who were not oped in order to highlight certain strengths and chal-
survivors of war and torture. In an effort to be responsive lenges which both workers and survivors experience
to this particular group of clients, the CHC endeavoured within the context of helping relationships.
to take action and engage the following research and
training project which held the following objectives: Results of interviews with survivors
Identify best practices in order to best serve Franco- The interviews with survivors of war, torture and
phone immigrants and refugees who are survivors of trauma enabled the research team to determine the types of
war, torture and organized violence; situations which the key informants faced as survivors, the
Develop a training manual for health care and challenges linked to their integration into Canadian society,
social service professionals working with this particular their needs relative to services and support as well as
clientele; solutions to the various challenges which they experienced.
Develop a pedagogical training video for all incoming The various forms of violence which the research
human resources working at the CHC; participants experienced were either linked to social situ-
Offer a series of training workshops in order to enhance ations, such as FGM, forced marriages, or to war and
the skills of health care and social service providers organized political violence. Research participants shared
working with this particular clientele. stories of being imprisoned, tortured by military or armed
In order to honour these objectives, researchers from individuals, rape and sexual harassment, witnessing the
Wilfrid Laurier University were called upon to work death of a loved one or enduring physical limitations due
within a framework of university/community collabora- to torture as well as experiencing trauma due to unsafe
tion in order to fulfill the mandate of the project: living conditions in refugee camps.
The research team conducted a thorough literature
review on the subject of trauma and the contexts of best Challenges linked to integration
practices in which to intervene. The literature review The research participants shared stories of being
enabled us to review hundreds of documents on different confronted with numerous challenges relative to their
types of trauma and ways in which professionals have integration within Canadian society. Several were still
worked with survivors within organizations dedicated to waiting to hear word on their status (i.e. refugee status,
survivors both in North American and African contexts; landed immigrant status, permanent resident status)
Sixty key informants were interviewed including 23 sur- which they said augmented their level of emotional and
vivors, 27 professionals working in health care and financial stress. Research participants shared the following
social services and 15 experts working in some capacity challenges as most important relative to their compro-
with survivors of war and torture. Among the experts mised ability to integrate within mainstream society:
interviewed, a few were survivors themselves and were Inadequate services linked to learning English;
now working either as researchers or in the area of Lack of information relative to education and train
health care or social services. ing needs;
University/community collaboration was the framework Frustrating lack of recognition of levels of education,

85
 Ginette Lafrenire AND Lamine Diallo

diplomas and work experience in countries of origin; vision relative to working with survivors of war, torture
Facing discrimination while attempting to access housing; and organized violence.
Physical or mental issues impeding the ability of survi- The research participants shared the following
vors to access and maintain employment; challenges and barriers which according to them, compro-
Accessing health and social services in French; mised their ability to work with survivors in an
Despite the difficulties which survivors shared with effective manner:
us, they nonetheless had very clear ideas on factors which
could ease their integration within Canadian society. The a. Communication
most important factor was the idea of having a guichet Communication was identified as the most chal-
unique, a one stop space whereby survivors could access lenging element of the work which characterized the
services in French for all levels of integration from relationships which professionals entertained with
accessing information for employment, housing, legal aid, survivors. Several health care and social service
health and social services. Not having to relate their providers felt that they did not have the necessary tools
horrific stories repeatedly was something which was of to adequately diagnose a client and several felt that they
the utmost importance for most of the research partici- were unsure in being able to assess if someone had
pants. For many, having to repeat their stories, deal with been tortured or not. Many shared feelings of inade-
systemic discrimination, racism and exclusion only served quacy and frustration given that they did not know
to aggravate their feelings of trauma and stress. Addition- many of the cultural practices of certain clients and that
ally, a very important factor which was shared by most of assessment tools, particularly as it related to mental
the research participants (survivors) was the idea that health, were culturally inapplicable to the clients which
those professionals working in the area of health and they were seeing.
social services needed to create spaces for dialogue Issues with accessing interpreters who could
around the idea of spirituality or religiosity. Finally, translate judiciously the thoughts and feelings of
survivors want to be heard. It was found that survivors survivors was an issue for several service providers who
wanted to be able to tell their stories and have the profes- felt that many ideas and information were lost in transla-
sionals with whom they were working believe their stories tion, thus compromising yet again the way in which they
and advocate for them. Also, the research participants could provide adequate service. Challenges with having
(survivors) wished to be active stakeholders on boards, or family members act as interpreters as well as individuals
committees which are dedicated to working with uncomfortable with the vocabulary of health and trauma
survivors in order that they can be agents of their own were also cited as being frustrating factors which impeded
program development and influence ways in which adequate service provision.
professionals work with survivors.
b. Professional competency
Results of interviews with health care Several service providers shared stories of feeling
and social service providers inadequate and at times vulnerable as they did not feel that
The health care and social service providers inter- they were providing adequate services to survivors. Several
viewed were primarily from the CHC in Hamilton as well experienced survivors as uncommunicative, uncooperative
as their satellite service in Welland, Ontario although relative to following and carrying out medical requests
some who were interviewed worked directly with (i.e. taking medication, following through on other tests,
survivors in other agencies. The professionals interviewed etc). A few service providers shared thoughts of feeling
were nurses, nurse practitioners, doctors, social workers, manipulated at times by survivors and had difficulties
community workers, educators and mental health coun- believing their stories. Others still, shared feelings of being
sellors. Fifty-one per cent (51%) were female and all horrified and overwhelmed by survivor stories. There is at
research participants had received post secondary times, tension and friction between service providers and
education. Most research participants stated that they had survivors whereby an aura of mistrust permeates both
never received training specifically related to working actors in the helping relationship.
with survivors of war, torture and organized violence.
Only 25% of research participants shared that they had c. Demystifying mental health services
received some training in working with survivors of For several health care and social service providers,
trauma and most stated that the training was insufficient a most frustrating element of their work is trying to
or did not specifically relate to survivors coming from explain and demystify the legitimacy of mental health
various cultural communities. All research participants services to survivors. According to the providers, not
stated that they would like to receive training and super- only do many survivors not know how to navigate the

86
 In the Interest of Working with Survivors of War, Torture and Organized Violence:
Lessons from a University/Community Research Collaborative in South-Western Ontario

health care system generally, there is a feeling that cophone immigrants and refugees is imperative in order
survivors do not understand the scope of mental health that socio-political spaces are shared and that harmoni-
services in particular. This idea is confirmed by some of ous alliances can be developed;
the survivors we interviewed who resist the idea of being Mental health services must be holistic and honour tra-
stigmatized as being crazy (their words) and thus do ditional forms of healing; this may include creating
not wish nor seek mental health services despite the fact spaces for religiosity and spirituality or creating spaces
that many present with symptoms related to trauma and for advocacy, truth and reconciliation initiatives or by
post traumatic stress. expanding services which could include art, music and
Other issues relative to religiosity and spirituality, other forms of complementary therapies;
vicarious trauma amongst service providers, and Honouring the different ways in which mental health
addressing tensions between Franco-Ontarians and Fran- services can reach out to men, women and children
cophone immigrants were highlighted within the context must be considered in order to effectively provide ser-
of the research as important issues which needed to be vices to various groups of survivors; paying attention to
further explored if service providers were to be able to the gendered realities of survivors is crucial in order to
adequately respond to survivor needs. address issues relative to trauma and PTSD;
The most important element which emerged Breaking down the misguided elevation of one form
from the provider interviews was the need for ongoing of practice (clinical) over another (community) in
training and supervision relative to the specificity of social services is crucial if providers wish to effectively
survivor needs. work with survivors; this means that creative commu-
nity based healing initiatives should be considered
Lessons learned and informed by survivors in order that veritable healing
can take place;
This project was and is important for all stakeholders Health and social service providers should be encour-
who wish to enhance services dedicated to survivors of aged to embrace the merits of research and ongoing
war, torture and organized violence. What we have evaluation of their practices in order to document
learned from this research is immeasurably important on and share promising practices with various stakeholders
many fronts. We have learned that: working with survivors of war, torture and organized
Working within a framework of university/community violence.
collaboration is an imitable form of community based
research as it creates spaces of equity and personal
agency for those who are most affected by the research;
Survivors wish to be heard and want health and social
service structures to honour their voices and experi-
ences in ways which do not treat them as exotic ele-
ments but as invested stakeholders who can enhance the
design and spectrum of services deployed towards
immigrants and refugees, many of whom are survivors
of war, torture and organized violence;
Health and social service providers must engage dia-
logue with their funders, managers, supervisors and
boards of directors in order to fully commit to the ardu-
ous task of re-examining the ways in which services are
dedicated to survivors and that these services are re-
designed to be more responsive to the needs of survi-
vors. Concretely this means being able to dedicate more
time to survivors within intake and helping relation-
ships, providing comfortable and nurturing physical
spaces which will minimize the chances of triggering
survivors, and providing training and supervision
opportunities to health and social service providers in
order to enhance service delivery. With regards to Fran-
cophone providers and survivors, creating spaces for
dialogue between Francophones de souche and Fran-

87
 Du global au local:
Repenser les relations
entre lenvironnement social
et la sant mentale des immigrants
et des rfugis
Ccile Rousseau diplme en mdecine de lUniversit de Sherbrooke a pratiqu 4 ans la mdecine gnrale au Guatemala.
Elle a complt ses tudes en psychiatrie transculturelle lUniversit de Montral et McGill. Elle travaille en soins partags dans
des quartiers pluriethniques avec le CSSS de la Montagne et poursuit ses recherches sur les programmes de prvention en milieu
scolaire pour les enfants immigrants et rfugis.
Ghayda Hassan est professeure adjointe au dpartement de psychologie de lUniversit du Qubec Montral (UQAM). Ses intrts
cliniques et de recherches se centrent autour de trois axes principaux de la psychologie clinique culturelle : 1) lintervention en
violence conjugale et les mauvais traitements envers les enfants dans un contexte de diversit culturelle; 2) lidentit et la sant
mentale des enfants et adolescents issus des minorits ethniques et 3) le vivre ensemble et les relations intercommunautaires.
Elle travaille au sein de lquipe dIntervention et de Recherche Interculturelle (ERIT) dirige par la docteure Ccile Rousseau,
o elle participe, entre autre, la formation et la supervision de stagiaires en psychologie clinique.
Nicolas Moreau dtient un doctorat en sociologie de lUQAM (Universit du Qubec Montral). Il est professeur remplaant
lcole de service social de lUniversit dOttawa, chercheur au sein des quipes MEOS (quipe du mdicament comme objet social)
et ERIT (quipe de recherche et dintervention transculturelles). Ses publications dans les champs de la sant mentale et de
linterculturel sont nombreuses.
Uzma Jamil est doctorante en sociologie lUniversit du Qubec Montral (UQAM). Elle est galement chercheure associe au
sein de lquipe de recherche et dintervention transculturelles de lUniversit McGill (ERIT). Elle travaille, Montral, avec les
communauts musulmanes dorigine sud-asiatique sur les questions de construction identitaire et de relations de pouvoir entre les
immigrants et la socit qubcoise et canadienne suite aux vnements du 11 septembre 2001.
Myrna Lashley is a professor of psychology at John Abbott College and a lecturer in the McGill University Summer School on
Transcultural Psychiatry. She is an internationally recognized clinical, teaching and, research authority in cultural psychology, and
serves as an expert psychological consultant to governmental institutions, including the juvenile justice system and federal, provin-
cial and municipal police systems. She has also worked as a consultant to First Nations and Jewish communities.

rsum
Dans le contexte de la guerre au terrorisme, laugmentation de formes explicites et implicites de discrimination
est associe plus de dtresse psychologique au sein de certaines minorits. Paralllement, lapparition de
stratgies daffirmation identitaire et dune cohsion interne accrue a des consquences sur le plan de relations
intercommunautaires.

88
 Du global au local : Repenser les relations entre lenvironnement social et la sant mentale des immigrants et des rfugis

Alors que beaucoup dtudes sur la sant mentale et coll. 2009) interroge 254 familles originaires des philip-
des immigrants et des rfugis continuent mettre pines et des carabes frquentant des coles secondaires
laccent sur la psychopathologie et les facteurs de risque Montralaises. La deuxime tude (Lashley et coll. 2005)
pr-migratoires, limportance de lenvironnement post- porte, quant elle, sur 63 jeunes originaires des carabes
migratoire simpose de plus en plus comme un dans les CEGEP anglophones de Montral. Les rsultats
dterminant majeur de la sant mentale de ces popula- rvlent que dans les deux tudes sus mentionnes, la
tions traditionnellement considres comme risque discrimination vcue est significativement plus prsente
(Porter et Haslam, 2005). Le phnomne de globalisation pour les jeunes issus des Carabes comparativement
entrane une transformation des phnomnes migratoires leurs pairs philippins (t = 4.38; p<.001). Dans les classes
et des relations internationales. Ainsi, les environnements de niveau secondaire, 12.7% des jeunes issus des carabes
daccueil voluent de faon rapide et exigent des change- disent avoir t frapps pour cause de racisme, 43.2%
ments paradigmatiques non seulement au niveau de la avoir t insults, 34.7% avoir subi des impolitesses et,
comprhension des enjeux pour la sant mentale des enfin 32.3% avoir t traits injustement. Dans le cadre de
immigrants mais aussi sur le plan de la planification des la premire tude, les analyses des rgressions logistiques
services et des programmes intersectoriels. montrent que la discrimination merge comme facteur
Cet article propose un survol dtudes qubcoises prdicteur significatif des troubles de comportements
rcentes, conduite par lquipe de recherche et pour les jeunes issus des Carabes et des Philippines alors
dintervention transculturelle (ERIT) ralises auprs que ceci nest pas le cas ni pour les variables dge et de
dimmigrants et de rfugis, dadultes et denfants, de la genre (classiquement associes ces problmes), ni pour le
grande rgion montralaise en ce qui a trait la dialec- vcu de sparation familiale pourtant trs frquent chez
tique entre les contextes local et international. En ces groupes de population. Globalement, la prvalence des
prsentant des recherches portant sur 1) les familles troubles de comportement chez les 254 jeunes recruts
originaires des philippines et des caribes anglophones, demeure significativement plus faible que chez leurs pairs
2) les communauts du Maghreb/Moyen-Orient et Qubcois dans les mmes environnements scolaires
hatienne ainsi que 3) les communauts musulmanes du (Rousseau, et coll. 2008). Cependant, chez les jeunes origi-
sud-asiatique, cet article se veut une rflexion sur les naires des Carabes, les problmes de comportement
associations complexes entre les spcificits qubcoises augmentent significativement avec la dure de sjour au
et canadiennes et les enjeux plus globaux. Nous interro- Qubec, ainsi que chez les jeunes de deuxime gnration.
geons les liens possibles entre des vnements publics (tels Les donnes qualitatives des deux tudes susmen-
que le dbat sur les accommodements raisonnables ou tionnes rvlent que la discrimination est au cur du
encore sur les vnements de Montral Nord), les vcu des familles et des jeunes rencontrs (et ce quils
nouveaux visages de la discrimination, la monte de la soient issus des carabes ou des philippines) (Rousseau et
suspicion face lAutre (gnralement associe la guerre coll. 2009). De plus, ces jeunes sindignent du silence et de
contre le terrorisme) et la sant mentale des familles la rsignation de leurs parents face la discrimination.
appartenant des communauts minoritaires. Alors que les jeunes Philippins conservent des espoirs de
changement et dascension sociale, ceux originaires des
Un futur impossible? Discrimination et Carabes sont plus pessimistes quant leurs possibilits
sant mentale pour les jeunes originaires de sortir de lexclusion sociale vcue leurs parents et
des carabes et des philippines. daccder des emplois correspondants leurs comp-
Deux tudes ralises entre 2004 et 2006 interro- tences. Les donnes sur les facteurs associs la russite
gent le dcalage entre, dune part, les perceptions des jeunes originaires des carabes dans les CEGEP
dinstitutions qubcoises, tels que les commissions rvlent que ceux-ci canalisent leur colre et leur rvolte
scolaires ou les services sociaux et de police qui rappor- face la discrimination et labsence de perspective
tent des problmes importants de comportement chez davenir en investissant, de manire rsiliente, dans leurs
les jeunes et, dautre part, la comprhension des tudes et en sappuyant sur leur confiance dans leurs
reprsentants des communauts qui peroivent les trans- familles et en Dieu. Plusieurs demandent Dieu de les
gressions des jeunes comme tant davantage le fruit de soutenir dans leurs efforts de russite et de les aider ne
facteurs environnementaux. Ces derniers soulignent le pas se fcher contre des figures dautorit du pays hte
rle de la discrimination qui survient dans un contexte (Lashley, et coll 2005).
dimmigration marqu par des sparations familiales Les rsultats de ces deux tudes mettent en lumire
prolonges fragilisant les familles (Lashley, 2000 ; la gravit des formes implicites et politiquement
Measham, 2002). correctes de racisme qui entretiennent lambigut et
La premire tude (Rousseau, et coll. 2008; Rousseau placent perptuellement ces jeunes et ces familles en

89
 Ccile Rousseau, Ghayda Hassan, Nicolas Moreau, Uzma Jamil et Myrna Lashley

position dagresseur, dans la mesure ou ils deviennent des participants arabes-musulmans contre les effets
dune certaine faon responsables des formes intangibles ngatifs de la discrimination en renforant leur sentiment
de discrimination quil dnoncent. dappartenance au groupe et en leur procurant confort et
soutien travers une plus grande observance des rituels
valuation : Perception de la discrimination religieux, possiblement, dans un geste de rsistance
(1998-2007) et sant mentale chez les (Bierman, 2006). Cette stratgie, a priori protectrice, peut
nouveaux arrivants toutefois constituer une arme double tranchant, puisque
En 1998, lenqute sur les communauts culturelles les solidarits religieuses et lexhibition des symboles et
du Qubec (ci-aprs ECC) a dress un portrait de la pratiques islamiques est aujourdhui perue comme une
sant des immigrants rcents (arrivs au Qubec depuis source de menace pour les valeurs et la scurit du
moins de 10 ans) issus des quatre communauts groupe majoritaire (Esses, Dovidio et Hodson, 2002).
culturelles suivantes : 1) Maghrebine/Moyen-Orientale,
2) chinoise, 3) hatienne et 4) hispanophone (ISQ, 2002). Faire sens dun contexte menaant
En 1998, les individus issus des communauts du et le transmettre : les familles musulmanes
Maghreb/Moyen-Orient rapportaient le plus faible taux du sud asiatique
de discrimination (25.8 %) comparativement aux Alors que la guerre en Irak menaait dclater, nous
membres de la communaut chinoise (39%), hatienne avons collabor avec certaines coles afin dessayer
(31.1%) et hispanophone (31.8%). La perception de la dattnuer les contrecoups du contexte international qui
discrimination constituait alors un dterminant plus se traduisent par une polarisation des revendications
important de la sant mentale chez les immigrants identitaires et religieuses dans certains quartiers
rcents que lemploi ou la matrise dune des deux (Rousseau et Machouf, 2005). Subsquemment, nous
langues officielles (Rousseau et Drapeau, 2002). avons mis sur pieds, en partenariat avec les communauts
En 2007, nous avons ralis une tude comparant, pakistanaise et Bengali, deux recherches qualitatives
laide des mmes chelles, la perception de la discrimina- portant sur la comprhension du contexte international et
tion chez deux de ces communauts (hatienne et les consquences possibles de ce dernier sur la sant
Maghrebine/Moyen-Orientale) aprs le 11 septembre mentale des familles dans le quartier parc Extension de
2001 afin de mesurer lventuel impact de la guerre au Montral.
terrorisme et du discours scuritaire sur les relations Une petite ethnographie comparant lexprience de
intercommunautaires. sujets pakistanais de Parc Extension celle de Pakistanais
Les rsultats montrent que la perception de la vivant Karachi (Rousseau et Jamil, 2008) a rvl que ces
discrimination a presque doubl de 1998 2007, et ce deux groupes de populations nadhrent pas aux thses
quelle que soit lorigine ethnique (hatienne ou arabe) ou occidentales dominantes dans les mdias au sujet des
religieuse (musulmane ou chrtienne) des rpondants. La attentats du 11 septembre. Ainsi, la thorie du complot est
discrimination perue passe de 31.1% en 1998 54.3% en largement reprise et le recours des preuves pour
2007 pour les hatiens et de 25.8% en 1998 37.4% en ltayer, voque en miroir les positions de ladministration
2007 pour les arabes. Nanmoins, et malgr cette crois- amricaine de lpoque. Au-del de ces convergences,
sance significative de la discrimination, les rpondants certaines diffrences apparaissent autour des possibilits
rapportent, en moyenne, moins de dtresse psychologique de sexprimer sur ces sujets. Karachi, les rpondants
quen 1998. De plus, si on compare les deux communauts donnent libre cours leur colre face aux contrecoups
culturelles entre-elles, on constate que limpact de la sociaux et politiques du contexte international dans
discrimination sur la sant mentale ngative (SCL-25) est, leur pays et face une ingrence trangre quils peroi-
en moyenne, plus lev chez les sujets arabes-musulmans vent comme injuste. Cela nest pas le cas Montral
interrogs en 2007, comparativement ceux de 1998. puisque la peur menant au silence et lvitement
Comment expliquer ces rsultats? Dune part, il semble prvaut, les individus ne se sentant pas assez en scurit
que lemploi qui tait dans une priode faste cette pour parler librement.
poque a jou un rle protecteur sur le plan de la sant tant donn lampleur du foss entre les perceptions
mentale. Dautre part, les expriences de discrimination des communauts et celles du pays hte, une recherche
semblent renforcer les solidarits communautaires, subsquente a essay de comprendre les modalits de
particulirement chez les participants arabes-musulmans. communication entre parents et enfants autour de cette
Ces solidarits se manifestent autour dun niveau de reli- dlicate question. Il sagissait de saisir le rle que les
giosit plus lev (r=.193, p<.05), qui son tour, est parents attribuaient aux coles quant au positionnement
associe une meilleure estime de soi collective(r=.304, moral de leurs enfants face un contexte international
p<.001). Ainsi, la religiosit protgerait la sant mentale omniprsent dans les foyers par le biais des mdias. Vingt

90
 Du global au local : Repenser les relations entre lenvironnement social et la sant mentale des immigrants et des rfugis

familles (parents et enfants) dorigine bengalaise ou paki- comprenant, en outre, une affi mation identitaire et une
stanaise ont particip des entrevues qualitatives. Les cohsion accrue des groupes qui se sentent menacs. Si
rsultats confirment lvitement et les peurs suscits par ces stratgies permettent tempora irement de maintenir
les questions de politique internationale. Alors que un quilibre, elles creusent aussi un foss de plus en plus
lensemble des parents reconnaissent le rle majeur de grand entre les communauts, entre la socit hte et les
lcole afin de sensibiliser et de mobiliser les enfants dans groupes minoritaires.
le cas de catastrophes naturelles, la plupart soppose ce Bien que toutes ces recherches prsentent des limites
que linstitution scolaire aborde les questions politiques, et doivent consquemment tre interprtes avec la
jugeant que les positions prsentes seront trop partiales. prudence requise, elles confirment lurgence de promou-
Leurs craintes sont que les ventuelles discussions autour voir des collaborations autour de llaboration de
de cette thmatique naggravent la polarisation existante programmes de lutte contre le racisme et la discrimina-
entre eux et nous. Les parents ayant une vision tion entre professionnels de la sant mentale, coles et
moins clive et plus rassurante de la socit hte ont, autres acteurs sociaux, tels que les mdias et la police.
quant eux, tendance confrer lcole un mandat Ces collaborations devraient, nous semble t-il, tre
dinformation et dducation autour de questions fondes sur des stratgies labores par et avec les
sensibles dont labord requiert un climat de respect familles appartenant aux minorits, en reconnaissant la
mutuel. Du ct des jeunes et des enfants, les rsultats lgitimit de leur rsistance face aux injustices sociales.
indiquent que ceux-ci peroivent et internalisent les peurs De tels programmes doivent aussi sadresser aux peurs et
de leurs parents, mme si, de par leur appartenance des aux sentiments de menace dune majorit fragilise pour
coles multiethniques, ils ont souvent des positions moins sadresser aux tensions qui, sils dbordent lespace social
tranches que leurs ains. Plusieurs jeunes ont galement Qubcois, y ractive de vieilles blessures identitaires. Les
mentionn avoir un rle actif jouer dans lamlioration interventions doivent tre repenses de faon cratrice en
des relations intercommunautaires, et ce en mettant misant sur les solidarits sociales existantes.
laccent sur leur capacit de complexifier les reprsenta-
tions de leur communaut ainsi quen promulguant les
solidarits entre jeunes.
Bibliographie
Conclusion
Lensemble des recherches voques suggre que BIERMAN, Alex. Does religion buffer the effects of discrimi-
nation on mental health? Differing effects by race. Journal for
lespace montralais du vivre ensemble est soumis des
the Scientific Study of Religion, vol. 45, (2006), p.551-565.
tensions croissantes, mme si celles-ci demeurent
gnralement en de de ce qui est rapport dans BOURGEAULT, Guy. La constance rsurgence du racisme.
dautres mtropoles multiethniques. Les tensions inter- Pourquoi? Racisme et discrimination Permanence et rsur-
communautaires locales sont associes par les gence dun phnomne inavouable Saint-Nicolas: Distribution de
communauts minoritaires aux conflits globaliss et aux livres, 2004, Univers, p. 260-280.
transformations des manifestations du racisme dans un ESSES, V.M., J.F. Dovidio, J et G. Hodson. Public Attitudes
contexte ou celui-ci, non seulement persiste, mais Toward Immigration in the United States and Canada in
resurgit (Bourgeault, 2004). Les communauts vivant la Response to the September 11, 2001 Attack on America.
discrimination raciale depuis longtemps subissent Analysis of Social Issues and Public Policy, vol.2, no 1, (2002),
galement le contrecoup du discours scuritaire mme si p 69-85.
elles ne font pas spcialement parties des communauts
actuellement vises (cf. communaut hatienne), comme HELLY, Denise. Are Muslims discriminated against in Canada
since September 2001? Journal of Canadian Studies, vol.36,
peuvent ltre les communauts musulmanes (Helly,
no1, (2004), p.24-47.
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Dune part, les peurs alimentes par une actualit tural Psychiatry, vol. 37, no 2, (2000), p. 201-215.
sensationnaliste autour dvnements publics (dbats
LASHLEY, Myrna., et coll. Student Success: The identification of
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Montral-Nord) gnrent une dtresse psychologique success. Montreal: FQRSC, (2005).
dautant plus importante que les reprsentations du
eux et nous sont nettement dichotomiss. Dautre MEASHAM, Toby. Childrens representations of war trauma
part, on assiste lmergence de stratgies de rsistance and family separation in play. Unpublished masters thesis,
Thse soutenue pra lauteur luniversit McGill, en 2002.

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PORTER, Matthew., et Nick Haslam,. Predisplacement and

Postdisplacement Factors Associated With Mental Health of
Refugees and Internally Displaced Persons: A Meta-analysis.
JAMA, vol. 294, no 5, (2005), p. 602-612.

RAZACK, Sherene. Casting out: The eviction of Muslims form

Western law and politics. Toronto: University of Toronto Press,
2008.

ROUSSEAU, Ccile., et Aline DRAPEAU, Sant mentale

Chapitre 11, Sant et bien-tre, immigrants rcents au Qubec :
une adaptation rciproque? tude auprs des communauts
culturelles 1998-1999, Montral: Les Publications du Qubec,
2002, p. 211-245.

ROUSSEAU, Ccile., et coll. Prevalence and correlates of

conduct disorder and problem behavior in West Indian and
Filipino immigrant adolescents (en ligne), 2008 (consult le 21-4-
2008). Sur internet : http://dx.doi.org/10.1007/
s00787-007-0640-1. doi:10.1007/s00787-007-0640-1.

ROUSSEAU, Ccile., et coll. From the family universe to the

outside world: Family relations, school attitude and perception
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Places, vol. 15, no 3, (2008), p. 721-730.

ROUSSEAU, Ccile., et Uzma JAMIL. Meaning and perceived

consequences of 9/11 for two Pakistani communities: From
external intruders to the internalisation of a negative self-
image. Anthropology and Medicine, vol. 15, no 3, (2008),
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92
Community Engagement and
Well-Being of Immigrants:
The Role of Knowledge
Yvonne Lai, Ph.D., is the Outreach Coordinator of the New Canadians Centre and the Peterborough Partnership Council for Immigrant
Integration. Her doctoral degree in Psychology utilized mixed methodology to explore the factors related to successful engagement of
immigrants in small urban communities.
Michaela Hynie, Ph.D., is Associate Professor of Psychology at York University and the Associate Director of the York Institute for
Health Research. Her research interests focus on culture, immigration and newcomer physical and mental health. Most recently, she
has been working on social support, mental health, and accessing health care with recent newcomers.

abstract
Participation, integration and engagement in ones community lead to a range of individual and community benefits.
However, civic and social engagement can be challenging for immigrants. We review the literature on community
engagement and present data on barriers and facilitators of community engagement in newcomer communities.

Community engagement has been recognized as organizations efforts to improve the social, economic
playing a central role in the well-being of individuals and and political engagement and integration of diverse
communities. Evidence for the benefits of integration community members (e.g., Singh and Hynie 2008).
into ones community comes from a range of disciplines,
using different terminology and focusing on different Benefits of Community Engagement
outcomes, but coming to similar conclusions. Community engagement can occur through both
Community engagement research in the context of social and civic participation. Social participation includes
immigration and ethnic minorities often focuses on informal activities, such as visiting with neighbours;
social exclusion of specific groups, where social and group activities, such as joining support groups; and activ-
structural barriers prevent certain social groups from ities in public spaces, such as attending community fairs
participating fully in their communities. Exclusion from or street parties. These activities build social networks
the social life of ones community has negative conse- and opportunities for participation in reciprocal social
quences for the well-being of excluded individuals, and support relationships. Civic participation is comprised of
that of the community as a whole. It prevents excluded volunteer activities for the benefit of others in the
individuals from having full access to community community and may be undertaken individually or in a
resources such as education, employment or housing, group. Examples of individual activities include voting
and from achieving socially valued capabilities. It can or signing a petition, while a group activity may be illus-
also lead to elevated levels of unemployment and social trated by one joining a community action group. Some
unrest, and a weakening of social values in the forms of participation include a mix of social and civic
community as a whole (Bhandari, Hovarth and To 2006; participation. For example, participation in a group asso-
Schellenberg and Maheux 2007). Social support ciated with ones place of worship may be social but also
researchers studying the social isolation of individuals, civic in nature, depending on the groups activities.
as opposed to groups, consistently find serious negative Participation in community events is both deter-
consequences for physical as well as psychological well- mined by, and results in, a feeling of attachment to a
being, with social isolation being linked to increases in community and concern for its outcomes. Chavis and
both morbidity and mortality even after controlling for colleagues refer to this feeling of attachment as a sense
other social and health related variables (House, Landis of community (Chavis et al. 1986). Having a psycholog-
and Umberson 1988). These findings support the ical sense of community has been associated with a
importance of governmental and non-governmental range of positive psychological outcomes. It enables

93
 Yvonne Lai and Michaela hynie

community members to develop emotional ties with tudinal Survey of Immigrants to Canada, Schellenberg
each other and to develop a sense of membership and and Maheux (2007) found a substantial portion of immi-
belonging. It imbues individuals with feelings of grants to Canada struggle to build social relationships in
autonomy, environmental mastery, and purpose in life. their communities. Seven percent of recent immigrants to
Research suggests that it also promotes personal growth Canada reported that lack of social relationships and
and self-acceptance (Evans 2007). interactions was one of their greatest challenges since
Community engagement by individuals also benefits arriving, more than the number citing discrimination or
the community as a whole by contributing to its social racism, access to housing or education, or access to
capital. Social capital refers to relationships and struc- professional services or childcare as one of their greatest
tures within a community that promote cooperation for problems. Rates of participation in volunteer activities are
mutual benefit (Minkler and Wallerstein 2005; Putnam lower among immigrants to Canada than among non-
1995). Social capital is observed in healthy communities immigrant Canadians, and especially among recent
with high levels of leadership, skills, networks, psycholog- immigrants. The results from the 2004 Canada Survey on
ical attachment to the community, understanding of Giving, Volunteering and Participating indicated that
community history, and critical reflection (Goodman et approximately 30% of immigrants volunteered between
al. 1998). Participation in community activities plays a key 2003 and 2004, in comparison with almost 45% of the
role in developing these resources. Social capital enables Canadian-born population (Statistics Canada 2006).
communities to maximize their potential, and progress Similarly, approximately 60% of immigrants voted during
from individual to collective action to achieve social and these years, compared to 75% of the Canadian-born popu-
political change that can more effectively influence the lation. These data show that immigrant community
well-being of community members (Butterfoss 2006). members experience less social and civic engagement
than their Canadian born peers. Given the benefits that
Participation among Immigrants engagement and participation can bring to individuals
Despite the benefits of active community involve- and communities, understanding variables that can
ment on individual and collective well-being, research increase community engagement in immigrant communi-
suggests that civic engagement may be decreasing in ties is essential.
inverse proportion to communities increases in diversity
through immigration and settlement. In the United Barriers to Engagement and Participation
States, residents in highly-diverse communities are less While recent immigrants may value participation,
likely to trust their neighbours, regardless of whether they research suggests that many experience social exclusion
are from different or same cultural groups (Putnam 2007). as a result of multiple barriers, which include language
They report lower socio-political control, lower confi- differences, time constraints, and discrimination
dence in political leaders, decreased instances of (Goodkind and Foster-Fishman 2002). Perhaps as a result
registering to vote, volunteering and charitable giving, of these barriers, immigrant families that are trying to
constricted social networks, and weak confidence in establish themselves in new environments typically rely
personal and collective efficacy in influencing community upon closely-knit, but small, social networks established
outcomes. These results persist even when controlling for within their cultural communities (Omidvar and
factors that have typically been associated with engage- Richmond 2003). In the Longitudinal Survey of Immi-
ment, such as increased pressure on time and financial grants to Canada, among immigrants who made new
resources. While similar research has not been conducted friends, three-quarters reported that at least half of these
in Canada, the tensions associated with reasonable new friends were of the same ethnic or cultural group
accommodation of cultural differences suggest decreased (Statistics Canada, 2005). Thus, new immigrants are more
social cohesion among at least some communities in the likely to establish social networks with individuals from
face of real or potential community diversity (Bouchard the same ethnic background as themselves. Moreover,
and Taylor 2008). they are more likely to volunteer with religious groups,
While all members of diverse communities may which are less likely to be integrated in the larger
demonstrate reduced engagement, enhancing community community, than with community service organizations
engagement among immigrant community members may (Scott et al. 2006).
be particularly challenging. Immigrant individuals and Other factors influencing participation that have
communities in Canada achieve social inclusion, identifi- been identified include the physical characteristics of the
cation and engagement in their communities with varying community (Oliver 2000), access to financial and time
degrees of success. In an analysis of data from the Longi- resources (McBride, Sherraden and Pritzker 2006) and

94
 Community Engagement and Well-Being of Immigrants: The Role of Knowledge

length of residence in Canada. Participation and They did not report feeling discriminated against, but,
community engagement may be particularly challenging rather, felt that community organizations were unaware
for recent newcomers because they are struggling with of the unique experiences and needs of new immigrants
limited personal resources. This lack of resources can and this discouraged them from participating.
make it difficult to provide support for others which At the same time, the participants reported very
prohibits participating meaningfully in reciprocal social little knowledge of opportunities for participation in their
support networks (Osborne, Baum and Ziersh 2009). community. Participants were unaware of any other
Thus, at a time when support networks might be most community organizations in Peterborough outside of the
needed, participating in social networks may actually settlement agency they were recruited through, including
increase immigrants stress and distress, rather than potentially useful services like Ontario Works, language
contributing to their well-being (Hynie and Cooks 2009; training classes, and Legal Aid. None of the participants
Stewart et al. 2008). talked about seeking volunteer opportunities via notices
Barriers to participation can also vary as a function on bulletin boards, despite wanting to feel that they were
of the size of the community to which newcomers have engaged in useful activities in the eyes of the community.
immigrated. Large metropolitan areas, like Toronto, facil- Moreover, none utilized the drop-in services at the Family
itate culturally-based social and community groups as Resource Centre, or sought counseling services either in
they are the hubs of immigration and sustain a large pool person or on the telephone via crisis help lines despite
of diverse immigrants. The situation is different in smaller reporting a need for these services.
urban municipalities. However, social isolation seems to Interestingly, and in contrast to findings from larger
have a weaker negative impact in small communities and metropolitan centres (e.g., Simich et al. 2005) participants
some researchers argue it may be because small urban did not highlight seeking support from other members of
centres foster more social integration (House, Landis and their own cultural groups. Rather, their support network
Umberson 1988). An interesting question is thus whether tended to consist of immigrants from other cultural
immigrants become more engaged in smaller communi- communities with whom they interacted at activities
ties. In one study conducted in Peterborough, a town of organized by the local settlement agency. By staying
approximately 71, 000 people, we interviewed recent within the comfort zone of these activities, immigrants
newcomers about the barriers they experienced to partici- exposure to services offered and activities organized by
pating in local community events and organizations (Lai other community agencies may have been limited.
2009) and found patterns of engagement that differed Likewise, their exposure to other community members
from those of larger metropolitan centres. was limited to only other newcomers using these services,
Twenty-one participants participated in semi- newcomers who also had limited knowledge of and
structured interviews about their participation and engagement with the larger community. This social
engagement. Participants came from a range of different network was therefore unlikely to help them build an
countries and had been in Canada for an average of about understanding of ways to engage and participate in the
18 months. These recent newcomers were satisfied with broader community. As a result, they may have been
the physical characteristics of their community and deprived of significant opportunities for assistance.
appreciated the relative calm and safety of being in a
smaller urban centre, and were optimistic about their The Role of Knowledge in Engagement
future there. Despite positive attitudes towards the In the study described above, several structural and
community, however, recent newcomers noted several personal obstacles emerged to recent newcomers engage-
barriers to engagement. Several structural barriers to ment and participation in their community. One barrier
engagement existed. For most newcomers, facility with that could easily be addressed, however, was a lack of
the English language was a major challenge, without information and knowledge about ones community.
which they felt as if they have their tongues cut off. Immigrants who were unfamiliar with the structure of
However, many were unable to attend formal and formal social support services in the community were
informal English language classes because of conflicts faced with navigating the system on their own or with
with work or childcare responsibilities, making this a informal assistance from friends who, in this case, often
difficult challenge to overcome. They also faced high rates had little more information than they did. It seemed
of unemployment, a challenge shared by many in this possible that increasing knowledge would be a simple
small urban centre. Participants also reported that they intervention to help promote engagement among
actively refrained from joining community activities newcomer communities. We therefore conducted a
because they felt that [staff and volunteers of commu- second study to evaluate whether increasing knowledge
nity-based organizations] cant understand immigrants. about a community issue of relevance to immigrants

95
 Yvonne Lai and Michaela hynie

would be sufficient to increase immigrant engagement in may struggle with limited resources, especially in the first
this issue. years of settlement. The increasing profile of diversity in
In collaboration with the Community Legal Clinic of Canadian society, occurring in tandem with the trend of
York Region, we created an education program about immigration, has the potential of adding vitality to
property by-laws for immigrant residents of Markham, a community life. Working with these communities to
moderately sized community (population over 260 000) build their capacity for engagement and well-being will
situated just north of Toronto. Seventy recent newcomers ensure that this potential is realized.
participated in the education session and completed brief
surveys before and after participation. Participants were
more likely to participate by signing a petition to change
property by-laws if they felt a stronger sense of References
community and community empowerment. A sense of
community, in turn, was related to their knowledge of the Bhandari, B. S., Horvath, S. and To, R. Choices and Voices of
Immigrant Men: Reflections on Social Integration. Canadian
Markham community. Increases in knowledge of the
Ethnic Studies 38 (2006): 140-148.
by-laws, however, did not increase participation by signing
the petition. These results suggest that the effects of Bouchard, G., and Taylor, C. 2008. Building the Future: A Time
knowledge on community engagement are tied to a sense for Reconciliation. Qubec: Commission de consultation sur les
of knowing the community, rather than just knowing pratiques daccommodement relies aux diffrences culturelles.
about specific issues. Indeed, knowledge of a community
Butterfoss, F. Process Evaluation for Community Participa-
may be a by-product of engagement, rather than the other tion. Annual Review of Public Health 27 (2006): 323-340.
way around. What seems most likely, however, is that
knowledge and engagement bear a reciprocal relationship Chavis, D. M. et al. Sense of Community Through Brunswicks
to one another; you need to know about opportunities to Lens: A First Look. Journal of Community Psychology 14 (1986):
participate in order to engage, but engagement in 24-40.
community activities will then increase your knowledge. Citizenship and Immigration Canada. Welcoming Communities
A greater focus on education and publicity may Initiative. 2006. http://atwork.settlement.org/sys/atwork_
therefore be beneficial to engaging community members, library_detail.asp?docid=1004152 (18 June 2009).
but it needs to be a broad-based education about
community norms, services and functioning, and it needs Citizenship and Immigration Canada. Local Immigration
to be paired with initiatives to reduce structural barriers Partnerships. 2008. http://atwork.settlement.org/sys/atwork_
to participation. Two recent initiatives by the federal library_detail.asp?doc_id=1004478 (18 June 2009)
government reflect these priorities. The Welcoming Evans, S. D. Youth Sense of Community: Voice and Power in
Communities Initiative is a series of strategies between Community Contexts. Journal of Community Psychology 35
federal departments, aimed at improving the awareness (2007): 693-709.
and knowledge of discriminatory practices, and
developing ways to counter these behaviours at a commu- Goodkind, J. R. and Foster-Fishman, P. G. Integrating Diversity
and Fostering Interdependence: Ecological Lessons Learned
nity-level. Another goal of the program is to increase
About Refugee Participation in Multiethnic Communities.
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Canada (Citizenship and Immigration Canada 2006). This
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Kretzmann 1990). At the same time, involvement of Kawachi, I. and Berkman L. F. Social Ties and Mental
government and non-governmental agencies to provide Health.Journal of Urban Health 78 (2001): 458-467.
additional support is essential to address the challenges
faced by newcomer individuals and communities who

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97
 Determinants of Mental Health
for Newcomer Youth:
Policy and Service Implications
Yogendra B. Shakya is the Director of Research at Access Alliance Multicultural Health and Community Services. His research
interests include social determinants of newcomer health, racialized health disparities, and globalization and community based
research.
Nazilla Khanlou is OWHC Chair in Womens Mental Health Research, Faculty of Health & Associate Professor, School of Nursing, York
University & Adjunct Professor, University of Toronto. Her research interests include mental health promotion among youth and women
in multicultural and immigrant-receiving settings. She was the Health Domain Leader of the Centre of Excellence for Research on
Immigration and Settlement in Toronto (2001-2008).
Tahira Gonsalves was the Research Coordinator for the Newcomer Youth Mental Health Project and is a PhD student in Sociology at
York University. Tahiras research interests include immigrant mental health and second generation youth religious identities.

abstract
Drawing on our study1 with newcomer youth from four communities in Toronto, this article discusses post-migration determinants of
mental health for newcomer youth in Toronto and reflects on policy implications. Preliminary study findings indicate that settlement
challenges and discrimination/exclusions are salient risks to the mental wellbeing of newcomer youth and their families.

Introduction the last decade from 28,125 arriving in 1999 compared

There is a paucity of Canadian literature on the to 37,425 arriving in 2008 (24.9% increase). The trend in
mental health of newcomer youth. Our study sought to newcomer youth migration to Canada since 1999 is
fill this gap by investigating the social determinants of presented in Figure 1. On average 35,000 immigrants and
newcomer youth mental health.2 We focused on refugee youth between the ages of 15-24 settle in Canada
newcomer youth (between the ages of 14-18 who have every year; this represents roughly 15% of the approxi-
been in Canada for five years or less) and their families mately 250,000 permanent residents that come to Canada
from four communities in the Toronto area: Afghan, annually. The composition of youth within refugees
Colombian, Sudanese, and Tamil. The project was settling in Canada is slightly higher (20.4%) compared to
grounded in an academic-community collaboration youth in other groups. The majority (79.8%) of youth who
between the Faculty of Nursing at the University of settle in Canada are from racialized visible minority
Toronto and Access Alliance Multicultural Health and backgrounds. A large percentage of immigrant youth
Community Services; we also incorporated several prin- settle in the three metropolitan cities in Canada (Toronto,
ciples of Community-based Participatory Research Montreal and Vancouver); immigrant youth thus
(CBPR) including involving newcomer youth from the comprise a significant segment of youth population in
four communities as peer researchers and as advisory these cities. In the City of Toronto, for example,
committee members. 3 Drawing on the qualitative immigrant youth between the ages of 15-24 constitute
component of our research, this article discusses the 39.5% of all youth in that age group.4
relationship between settlement stressors, discrimina- According to the 2006 Canadian Census, the unem-
tion/exclusion, and the mental health of newcomer youth ployment rate for recent immigrant youth was 15.4%
and their families. compared to 12.5% for Canadian-born youth. More strik-
ingly, the low-income rate for recent immigrant youth was
Snapshot of Newcomer Youth in Canada 3 times higher (45.8%) than that of Canadian-born youth
The number of newcomer youth between the ages of (15.7%) (Census Canada 2009).
15-24 settling in Canada has been steadily growing during

98
 Determinants of Mental Health for Newcomer Youth: Policy and Service Implications

Settlement Related Stressors and Mental etc). Youth identified the mental health implications of
Health of Newcomer Youth these settlement related challenges including stress, low
We asked newcomer youth from all four communi- self-esteem, anxiety, worry, sadness and depression.
ties to identify key stressors and challenges that they and Below, we focus our discussion on settlement stressors
their families face and how these stressors impact their related to linguistic barriers, adjusting to Canadian educa-
general and mental wellbeing. Study findings indicate tional system, and barriers entering the labor market.
that the majority of stressors, barriers and challenges Newcomer youth, their parents, and service
faced by newcomer youth and their families are related to providers identified linguistic barriers as one of the
settlement and discrimination/exclusion. biggest challenges in the settlement process. Our findings
Settlement related stressors are ones that are experi- suggest that having no or low English language fluency
enced due to being new to the country and/or due to amplify the barriers and challenges that newcomer youth
limitations in settlement policies and services for face including difficulties in making friends, under-
newcomers. Other researchers have also highlighted that standing the teacher and curriculum being taught, and
the immigration and settlement process itself is a major being bullied due to having low English fluency or having
stressor and that settlement related challenges can accents; in turn, these experiences resulted in low self-
compound mental health issues among newcomer youth esteem and compounded stress and anxiety. Youth also
(Anisef and Kilbride 2000; Beiser and Hyman, 1997; Berry discussed stressors related to learning English, particu-
et al., 2006; Khanlou et al., 2002; Ngo and Schliefer 2005). larly in ESL classes. They pointed out that while they are
Our study adds to this body of evidence on settlement able to learn English more easily than adults, there is
related mental health stressors. some stigma associated with being an ESL student. The
Linguistic barriers (including challenges with following quote from a service provider exemplifies the
learning English), barriers in entering the labor market negative perceptions that newcomer youth and others
(particularly for parents and older relatives), and chal- may have about being an ESL student:
lenges associated with adjusting to the Canadian The kids at the same time feel as though
educational system were identified as major settlement they are less worthy than the regular
related stressors by newcomer youth from all four students because they are in the ESL
communities. Youth also discussed isolation and access/ classes. With the ESL, many think that
information barriers that they face. They also talked about because you dont have English, then you
acculturation challenges to a host of formal and informal dont have the intelligence so the
processes (including to Canadian laws, communication material that is being taught is like
patterns, food and customs, cold weather, dating system kindergarten material.

Figure 1: Permanent Resident Arrivals in Canada, Ages 15-24, by Category, 1999-2008

45,000

40,000

35,000

30,000

25,000

20,000
Other
15,000
Refugees
10,000
Family class
5,000
Economic Immigrants*
0 *includes principle applicants,
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 spouses and dependents

Source: Citizenship and immigration Canada. Developed by Access Alliance.

99
 Yogendra B. Shakya, Nazilla Khanlou and Tahira Gonsalves

Adjusting to the Canadian education system also Discrimination/Exclusion as

appears to be a major stressor for newcomer youth due to Determinant of Mental Health
multiple barriers they face within the system. Several Many youth from our study (all from racialized back-
newcomer youth indicated that they had faced barriers in grounds) talked about having experienced (or witnessed)
getting their foreign academic credentials recognized by discrimination after coming to Canada, particularly race-
their educational institutions leading to misplacement in based discrimination. We also found that racialized
grades and courses. Other stressors include inadequate newcomer youth are aware of multiple forms of systemic
academic bridging support to newly arrived immigrant social exclusions that they, their families and their
students, lack of guidance in managing the heavy load of communities (ethnic and geographic) face. For example,
school assignments (compared to back home), and youth expressed deep concern about the way some
bullying. They pointed out that adjusting to these new teachers streamlined racialized youth into non-academic,
systems was quite stressful for them and their parents trades based programs and careers, regardless of their
(who have to help them with their school work). actual aspirations. Several youth also pointed out the
Our study findings indicate that the most profound disparities in services in neighborhoods with high
stressor on newcomer youth results from the barriers that immigrant and racialized populations.
their families (particularly their parents) face in entering Several studies have examined the relationships
the Canadian labor market. Newcomer youth (between between perceived discrimination, mental health and
the ages of 14-18) are less concerned about getting jobs for well-being, and ethnic/racial identity of immigrant youth
themselves since at this age they are mostly interested in populations (Phinney & Devich-Navarro, 1997; Jakinskaja-
getting part-time jobs, which they mentioned are fairly Lahti & Liebkind, 2001; Verkuyten, 2002; Shrake & Rhee,
easy to get. However, the majority of youth in our study 2004; Khanlou, Koh & Mill, 2008). Studies in Canada and
emphasized that the difficulties that their parents face in the United States have found negative physical and
entering the Canadian labor market not just undermined psychological health outcomes, such as elevated stress,
the income security for their families but also was a key lowered self-esteem, depression and behavioral problems
cause of depression, sadness, family tensions and other (e.g. violence and drug use) related to perceived discrimi-
mental health stresses on their family. Our study reveals nation and experiences of racism (Dubois et al.,
that newcomer youth are acutely aware of the labor 2002; Noh, Kaspar, Beiser, Hou, & Rummens, 1999; Surko
market challenges that their families face and the et al., 2005).
resulting socio-economic impacts (de-professionalization, Youth respondents recounted with sadness the direct
income insecurities) and mental health impacts. The experiences of race-based discrimination that they have
following narrative illustrate this point: faced or witnessed, often from teachers and people who
Sometimes my mom regrets coming are supposed to assist youth. Youth talked about being
from Colombia to here because she had a shocked, hurt and getting really mad due to these expe-
really good job over there too and she riences of race-based discrimination.
had everybody there to support her I An Afghan newcomer youth described his experi-
think coming from that great job that ence with racism and its impact in the following way:
you had, coming to something lower is When I first came here, everyone was
very hard for them because they want making jokes about Afghanistan and
the best for their kids. When I was terrorists. So every time I told them I
smaller, and spent two years here was Afghan, theyd ask me if I was a
already, I used to tell her that I hated her terrorist. So like that really hurt. So
for making me come here and I guess after that every time people would ask
that didnt help her much but now I me questions like that, Id start asking
support her because I know that she just them questions. So if theyd ask me if I
wanted the best. Sometimes she gets was a terrorist, Id say, do you see a
depressed because of her job and stuff. bomb on me?
Many of the youth respondents mentioned that while Similarly, a Colombian youth mentioned how his
they could assist their families in overcoming other supply teacher had said that he wished he could close the
barriers and stressors (for example, acting as interpreters border for Latin people because he hates them. Several
and service navigators for their parents), there was little Sudanese youth critiqued how people immediately associ-
they could do about the labor market barriers that their ated them with war and the Darfur region when they said
parents faced. that they were from Sudan.

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 Determinants of Mental Health for Newcomer Youth: Policy and Service Implications

The following quote from a Tamil youth illustrates that teachers who offer proactive support and are
the sadness and long term impact (on self confidence welcoming and respectful help to make them feel
and communication) that experiences of discrimination comfortable and included. As one youth put it:
can have: Mostly, [teachers] know its hard and
You get sad and become sad and you they ask personally, you know, youre
dont feel comfortable enough to talk to always welcome to come and see me
people more often. So you try to avoid they make you feel more comfortable. It
talking to different people. So you ask depends on the teacher.
yourself why, theyre only making fun of Our study has also documented many examples of
you. So you stop talking to them. youth resilience, optimism and leadership. Some youth
talked about how they help their families to navigate and
Strategies and Barriers in Addressing access services and assist with interpretation and transla-
Mental Health Determinants/Issues tion in English for family members facing linguistic
Preliminary analysis of our findings suggests that barriers. Some youth also mentioned that compared to
newcomer youth and their families rely more on informal adults, it was easier for them to make friends and that
systems of support rather than on formal services for they made friends like crazy. Youth in our focus groups
emotional/mental support as well as for help in over- often mentioned how they had gotten over things, or
coming the determinants/stressors. In particular, moved on. However, as noted in the earlier section,
newcomer youth from all four communities indicated that newcomer youth usually felt helpless when it came to
they do not have adequate knowledge about the mental critical systemic stressors like labor market challenges,
health service sector in Canada and that they and families income insecurity, and racialized discrimination/
rarely access formal mental health services. For example, exclusion that they and their families face.
many youth in the study mentioned that they are not
used to going to guidance counselors at their school even Conclusion
though they may be aware that it is a good thing to do. Findings from our study indicate that many determi-
One youth recounted how crisis counseling was available nants of the mental health of newcomer youth and their
at her school after a shooting incident. While she families are closely linked to settlement related stressors
acknowledged that it was a very good thing she did not and barriers. We argue that settlement is a health issue
avail of it, also mentioning that she did not have anything and highlight that current limitations in settlement
like that back home. policies and services not only undermine the socio-
Youth from all four communities identified family, economic wellbeing of newcomer youth and their families
friends, ones ethnic community, and religious institu- but also pose multiple risks to their mental health. Our
tions as their first and often the only sources of study also found that systemic discrimination and exclu-
emotional and other support. Our findings suggest that, sions are salient risks to the socio-economic and mental
newcomer youth negotiate and utilize these informal wellbeing of racialized newcomer youth and their families.
systems of support in strategic ways based on kinds and Based on our analysis, we recommend a multi-
levels of support each informal system can offer. For pronged approach to promoting the mental health of
example, most youth said that they preferred going to newcomer youth that includes (1) proactively addressing
their friends because you can tell them anything and the determinants of newcomer youth mental health,
there is no obligation to follow the advice that friends particularly those linked to settlement and discrimina-
give, unlike with parents and other adults. Several youth tion/exclusion(2) making mental health services more
indicated that they often provide emotional and other sensitive and accessible to the needs of diverse newcomer
support to their friends when needed. communities; (3) implementing innovative mental health
Many youth viewed their ethnic community as an promotion (MHP) programs that help to overcome
important source of support since there is always stigma, and build positive knowledge about mental health
somebody to help you. Several youth (including those that issues; (4) promoting collaboration between the settle-
are not necessarily religious) identified religious institu- ment and health sectors; and (5) implementing youth
tions as comfortable spaces for seeking settlement advice empowerment and community development programs
and other support. that build youth leadership and involve newcomer youth
In terms of formal supports, youth talked about the meaningfully as agents of change in critical pathways
role of teachers, ESL classes, and youth-focused programs (research, planning, decision making, community
offered in their schools and their neighborhoods building etc).
(homework clubs, youth sports clubs). Youth highlighted

101
 Yogendra B. Shakya, Nazilla Khanlou and Tahira Gonsalves

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Immigrant youth in cultural transition: Acculturation, identity Work in Mental Health 3(3) (2005): 235-60.
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Choi, H. Understanding adolescent depression in ethnocultural footnotes

context. Advances in Nursing Science 25(2) (2002).: 71-85.
1
The Newcomer Youth Mental Health Project was funded by
Citizenship and Immigration Canada. Facts and figures 2008: the Provincial Centre of Excellence for Child and Youth
Immigration overview. 2009. http://www.cic.gc.ca/english/ Mental Health at CHEO. Dr. Khanlou and Dr. Shakya were
resources/statistics/menu-fact.asp (14 Dec. 2009). Principal Investigators. Dr. Carles Muntaner was Co-Investi-
gator.
Galabuzi, G. 2001. Canadas Creeping Economic Apartheid: The
economic segregation and social marginalization of racialized 2
Our investigative and analytical framework is grounded in a
groups. Toronto, ON: Center for Social Justice Foundation for social determinants of health (SDOH) perspective since the
Research and Education. focus of our study is less on diagnostic processes for acute
mental illnesses and more on understanding systemic risks
Jakinskaja-Lahti, I., and K. Liebkind. Perceived discrimination
and stressors to mental wellbeing and access barriers to
and psychological adjustment among Russian-speaking
mental health services.
immigrant adolescents in Finland. International Journal of
Psychology 36 (3) (2001): 174-185. 3
The study employed mixed-methodology comprising of focus
groups, interviews and a questionnaire that included three
Khanlou, N. Influences on adolescent self-esteem in multicul-
psychometric instruments: Rosenberg Self-Esteem Scale (RSE),
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(2004): 404-411.
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Khanlou, N., M. Bieser, E. Cole, M. Freire, I. Hyman and K. Scale (CSE). We held a total of 6 focus groups with youth (2
Kilbride. 2002. Mental Health Promotion Among Newcomer Afghan, 2 Colombian, 1 Sudanese, 1 Tamil) 1 focus group with
Female Youth: Post-Migration Experiences and Self-Esteem. service providers, 16 in-depth interviews (2 Afghan youth, 4
Status of Women Canada. Health Canada. Sudanese youth, 4 Sudanese parents, 1 Colombian parent, and
5 service providers). The questionnaire was administered to 56
Khanlou, N., J. Koh and C. Mill. Cultural identity and experi- youth.
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immigrant youth. International Journal of Mental Health &
4
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Addiction 6(3) (2008): 494-513. 2008.

102
The Mental Health of Immigrant
and Refugee Children in Canada:
A Description and Selected Findings
from the New Canadian Children
and Youth Study (NCCYS)
Morton Beiser is Professor of Distinction and Program Director Culture, Immigration and Mental Health, Dept of Psychology, Ryerson
University; Crombie Professor Emeritus of Cultural Pluralism and Health, University of Toronto; and Founding Director and Senior
Scientist, Ontario Metropolis Centre of Excellence for Research on Immigration and Settlement (CERIS). Past academic appointments
include Associate Professor of Behavioral Sciences, Harvard School of Public Health (1965-1975); Professor and Head, Division of
Cultural Psychiatry, Dept of Psychiatry University of British Columbia (1975-1991), David Crombie Professor of Cultural Pluralism
and Health, and Head, Culture, Community and Health Studies, University of Toronto (1975-2002).

abstract
One in five children living in Canada was born either outside the country or to recently arrived immigrants. Helping the children of
new settlers adapt to their schools, integrate with the larger society and stay happy and healthy during the process are important goals
for all immigrant receiving countries. However, there is a dearth of knowledge about what promotes adaptation and integration on the
one hand, and what jeopardizes the well-being of immigrant and refugee children on the other. This article describes the New Canadian
Children and Youth Study (NCCYS), a longitudinal investigation of personal and contextual factors affecting immigrant and refugee
childrens health, mental health and development, designed to fill some glaring gaps in current knowledge.

Acknowledgements:
This paper is a product of the New Canadian Children and Youth Study (Principal Investigators: Morton Beiser, Robert Armstrong, Linda
Ogilvie, Jacqueline Oxman-Martinez, Joanna Anneke Rummens, Anne George, David Este, Lori Wilkinson), a national longitudinal survey
of the health and well-being of more than 4,000 newcomer immigrant and refugee children living in Montreal, Toronto, Winnipeg,
Edmonton, Calgary and Vancouver. The NCCYS is a joint collaboration between university researchers affiliated with Canadas four
Metropolis Centres of Excellence for research on immigration and settlement, and community organizations representing Afghani, Hong
Kong Chinese, Mainland Chinese, Latin American (El Salvadorian, Guatemalan, Colombian), Ethiopian, Haitian, Iranian, Kurdish,
Lebanese, Filipino, Punjabi, Serbian, Somali, Jamaican, Sri Lankan Tamil, and Vietnamese newcomers in Canada. Major funding for the
project has been provided by the Canadian Institutes for Health Research (CIHR grants FRN-43927 and PRG-80146), Canadian
Heritage, Citizenship and Immigration Canada (CIC), Health Canada, Justice Canada, Alberta Heritage Foundation for Medical
Research, Alberta Learning, B.C.Ministry of Social Development and Economic Security, B.C. Ministry of Multiculturalism and Immigra-
tion, Conseil Quebecois de la Recherche Sociale, Manitoba Labour and Immigration, and the Montreal, Prairies, and Ontario Metropolis
Centres of Excellence for research on immigration and settlement.

103
 Morton Beiser

Introduction and Background important questions, for example: Did the good news
As part of Canadas commitment to a national chil- about mental health apply to all children, refugee and
drens agenda, Statistics Canada and Human Resources immigrant alike? To visible minority as well as non-visible
and Social Development Canada (HRSDC) initiated the minority children? and, did factors such as the circum-
National Longitudinal Survey of Children and Youth stances of migration or region of resettlement in Canada
(NLSCY) in 1994, a long-term study focused on the have mental health effects? The NLSCY sample of
development and well-being of more than 35,000 immigrant children was too small to permit investigation
Canadian children from birth to early adulthood. This of such questions.
still-ongoing study is producing valuable information
about factors influencing childrens social, emotional and The New Canadian Children and
behavioural development. However, because immigrant Youth Study (NCCYS)
and refugee children are severely underrepresented in Investigators affiliated with the BC, Prairies, Ontario
the sample, insights gleaned from the NLSCY tell only and Quebec Metropolis Centres of Excellence on immi-
part of their story. gration research initiated the NCCYS to investigate
Migration and resettlement create unique develop- questions about the health, mental health and develop-
mental challenges. Policy makers and the helping ment of immigrant and refugee children that would
professions need to understand what these challenges are, contribute to the advancement of theory and to the devel-
how children and their families respond to them, which opment of policy and practice. Start-up funding from the
responses are successful and which are harmful. federal departments of Health Canada, Canadian Heritage
An article that several colleagues and I published a and Citizenship and Immigration Canada, from the four
few years ago (Beiser et al 2002) containing a surprising Metropolis centres, from the Fonds de la recherche en
finding about immigrant children attracted a flurry of sant du Qubec (FRSQ) in Quebec and Alberta Heritage
media attention. It also stimulated the creation of the Foundation for Medical Research (AHFMR) in Alberta
New Canadian Children and Youth Study (NCCYS). supported the development of an interdisciplinary team
This was the surprise. Poverty is one of the most made up of approximately 30 researchers from many of
potent of all factors that place childrens mental health Canadas leading universities partnered by local
at risk. Using data from the first wave of the NLSCY, immigrant and service-provider communities. The study
my colleagues and I compared mental distress and team developed a research framework focusing on risk
behavioural problems within the NLSCYs small sample and protective factors important for the mental health of
of immigrant children and native-born children. all children, such as parental mental health, poverty and
Since immigrant families were more than twice as likely parenting styles which could be considered universal risk
as non-immigrants to be living in poverty, we hypothe- and protective influences, and factors more or less specific
sized that immigrant children would have higher rates of to the immigration and resettlement experience, such as
distress and disturbance. The findings were the exact discrimination, the struggle with competing ethnic and
opposite: foreign-born children had fewer emotional and civic identities, and the availability of a like-ethnic
behavioural problems than their native-born counterparts. community as a source of social support. According to the
Further probing of the paradox highlighted the role NCCYS framework, immigrant and refugee childrens
of the immigrant family as a source of resilience. Poor well-being results from a dynamic process, the compo-
immigrant families were much less likely than poor nents of which include individual characteristics, pre- and
native-Canadian families to be broken families, and poor post-migration stressors, and the individual and social
immigrant parents were less likely to be ineffective or resources children use to cope with stress.
dysfunctional parents. Although the material effects of The NCCYS team compiled a questionnaire covering
poverty affected the mental health of both immigrant and universal and immigration specific general health and
non-immigrant children, the strength of immigrant mental health risk and protective factors. After master
family life apparently mitigated its psychological toxicity. versions of the questionnaires were prepared in English
Since the immigrant families studied had all been in and in French, community advisory councils made up of
Canada ten years or less, it is tempting to speculate that community representatives examined each question to
hope helped sustain them through the initially difficult determine its acceptability, and cross-cultural translat-
years. Anecdotal evidence suggests that many new settlers ability. The questionnaires were translated into 15
perceive poverty and its effects as bumps along the road to different heritage languages, and then back-translated.
eventual integration. By contrast, for far too many poor When discrepancies between the original and back-trans-
native-born Canadian families, poverty is the end of the lated versions of a particular question arose, the
road. The study raised a number of intriguing and community councils examined them to determine

104
 The Mental Health of Immigrant and Refugee Children in Canada: A Description
and Selected Findings from the New Canadian Children and Youth Study (NCCYS)

whether a better translation was possible. The relatively are factors specific to the immigrant experience that have
few questions that defied translation had to be dropped. to be taken into account, the second to explore the mental
The study involved six citiesMontreal, Toronto, health salience of two immigration-specific factors
Winnipeg, Edmonton, Calgary and Vancouver and country of origin and region of resettlement in Canada.
16 ethnocultural communities. A number of criteria To address these two questions, the article focused on the
guided the selection of target groups for the study: NCCYSs three national groupsHK Chinese, PRC
. Significant presence: Within each of the regions, the Chinese and Filipino.
team selected three country-of-origin groups that were The results showed that, in many ways, immigrant
among the top ten with respect to numbers of new settlers childrens mental health is affected by the same factors
during the ten years prior to the initiation of the study. that affect the mental health of children in general. For
According to 2001 census data, the three groups quali- example, boys were more likely than girls, and younger
fying for inclusion according to this criterion were: Hong children more likely than older, to display physical aggres-
Kong (HK) Chinese, Chinese from the Peoples Republic sion. As is the case for children in general, maternal
of China (PRC) and Filipino. 2. Groups of particular depression increased the probability that an immigrant
interest. In order to investigate the effects of immigrant child would have emotional problems.
versus refugee status, visible minority status, and the However, in addition to risk factors such as parental
availability of an established like-ethnic community mental disorder and protective factors such as good
during the time that new settlers arrive, we selected family functioning that affect the mental health of all
communities within each region in order to ensure that at children, factors more or less specific to the immigrant
least one case in the total sample fit each possible study experience affected the mental health of children in newly
profilefor example, refugee, visible minority, non-estab- resettling families, net of universal risk and protective
lished community; or immigrant, non-visible minority, factors. Immigrant children whose parents spoke little or
established community. In addition to the three national no English or French were more distressed than children
samples, that were represented at each site, there were whose parents had better degrees of linguistic fluency,
site-specific samples (defined by source country and/or immigrant children whose parents were suffering a good
ethnicity) as follows: 1. Vancouver: Iran, Afghanistan, deal of resettlement stress and who had experienced
India (Punjabi) 2. Prairies; Vietnam, Central America, discrimination had an elevated risk of emotional problems
Kurdish 3. Toronto: Serbia, Ethiopia, Sri Lanka (Tamil) and of physically aggressive behaviour.
4. Montreal: Haiti, Lebanon. The mental health salience of the country of origin
The NCCYS team focused on two age groups and the region of resettlement were the two most original
children between the ages of four and six (to make it findings of the study.
possible to follow children through the important devel- PRC Chinese children experienced a lower risk of
opmental stage of starting school) and 11 to 13 (in order developing mental health problems than either HK
to follow children from pre-adolescence into early Chinese or Filipino youngsters. These findings call
adolescence). attention to the circumstances of their familys migration,
With the partnerships and collaborative arrange- in particular the phenomenon of transnational families.
ments in place, the NCCYS researchers developed and Filipino migration is often initiated by women who
pilot-tested questionnaires for the planned biennial respond to inducements such as those offered by Canadas
interview with parents and children. We then applied for, live-in care-giver program that offers the possibility of
and received funding from the Canadian Institutes of landed immigration status after a mandatory period of
Health Research to conduct two waves of interviews with service caring for children or the elderly. During the three
the parents and children taking part in the NCCYS. The to four years it takes to establish their status and save
two survey waves have now been completed. enough money to re-unite their own families, the womens
own children stay behind in the home country with their
Results from Wave 1 of the NCCYS fathers or members of the extended familyWhen family
The first publication from the NCCYS, a paper reunification eventually takes place; it can be complicated
entitled Predictors of emotional problems and physical by childrens resentment over perceived maternal aban-
aggression among children of Hong Kong Chinese, donment. Immigration from Hong Kong is very different.
Mainland Chinese and Filipino immigrants to Canada Many HK Chinese families apparently came to Canada
which appeared in the journal Social Psychiatry and with plans to stay long enough to ensure their children
Psychiatric Epidemiology. The article had two major aims, education, but with the ultimate goal of returning to the
the first to demonstrate that, over and above the factors home country. Authorities have raised concerns about the
that affect the mental health of children in general, there possible mental health consequences of prolonged

105
 Morton Beiser

parental absences, and of pursuing the goal of returning Future analyses of NCCYS data will be concerned
to their country of origin rather than of integrating into with defining indices of immigrant receptivity, and
the society of the host county. By contrast, PRC Chinese comparing these across regions in an attempt to explain
families migrate as intact units with the goal of the regional differences displayed in immigrant childrens
permanent settlement. Although it is tempting to mental health. School climate will be one of these indices.
speculate that the increased mental health risk among HK An NCCYS paper recently submitted for publication
Chinese and Filipino children may be at least partially (Hamilton et al unpub,) examined relationships between
attributable to parental absences consequent on transna- childrens mental health and parents perceptions of their
tionalism, drawing such conclusions would be premature. schools. Schools with the most negative parental ratings
Future analyses of NCCYS data is anticipated and will were the schools in which immigrant children showed the
examine whether the findings can be explained by separa- highest levels of physical aggressiveness. It remains open
tions between parents and children, or whether other to question whether poor school environments jeopardize
explanatory factors are at work. mental health or whether parents of disruptive children
Since family separation is, to a certain extent, blame the schools for their childrens bad behaviour. The
amenable to changes in policy, these results cast a poten- longitudinal data will help determine the sequence of
tially important light on the importance of speeding up events. Regardless of causal direction, the findings point
family reunification. With respect to services, if children to the need for schools to improve communication with
in transnational families are indeed subject to particular the parents of immigrant children.
mental health risks, meeting their needs may call for Canada expects a great deal from newcomer
special training programs for service providers, including children. Immigrant parents also have high hopes for
the need to plan for family life post-reunification. their children. To help both families and the country
Despite Torontos reputation as a multicultural city, realize their aspirations, we need to know a great deal
immigrant children living there had worse mental health more than we currently do about what jeopardizes
than children living in the other five NCCYS sample immigrant childrens mental health and what factors
cities. Although the gaps have been closing in recent personal, familial, social and societalhelp ensure their
years, the children in the NCCYS sample spent their early well-being and success. Adapting to and integrating with
years in regions of the country that offered newcomers a new society are not easy tasks. The fact that most
differing levels of hospitality, that is macrosocial immigrant children meet the challenge is testimony to
climates that can affect mental health. Inter-provincial their resilience, a resilience based on personal qualities,
disparities in the amounts of money spent per immigrant the strength of the immigrant family and to the social
[Canadian Task Force 1988, CIC 2006) translate into resources they manage to find in Canada. All is not well,
differential access to language training, day care, job however, if almost a third of immigrant families with
training programs and health care, each of which may children live in poverty, if one in five immigrants experi-
affect the well-being of parents and children. ences discrimination, if parents feel alienated by their
In the early 1990s, immigration began taking on childrens schools, and if there are disparities in well-
cachet in Quebec, the Prairies and British Columbia. For being traceable to where people choose to live in Canada.
example, in 1991, the federal government signed an accord More can and must be done to ensure that immigrant
with Quebec, devolving jurisdiction as well as funding for children become part of Canadas childrens agenda.
settlement and integration services to the Province.
Similar accords were signed with Manitoba in 1996, with
British Columbia in 1998, and with Alberta in 2002. By
contrast, during the mid- to late 1990s, Ontario provided
severely limited amounts of the kinds of social support
that many immigrant families require during the early
years, remained cool towards immigrants, and suspicious
of federal policies of devolution. It was not until 2004 that
the province signed an initial letter of intent to proceed
with negotiations regarding immigrant selection, destina-
tion and integration. Despite being the largest magnet for
immigrants, Ontario may not have presented the most
welcoming environment.

106
 The Mental Health of Immigrant and Refugee Children in Canada: A Description
and Selected Findings from the New Canadian Children and Youth Study (NCCYS)

References

Peer-Review Journals

Beiser, M. Hou, F., Hyman, I., Tousignant, M., Poverty and

Mental Health Among Immigrant and Non-immigrant
Children. American Journal of Public Health. 2002, Vol 92 No.
2, 220-227.

Beiser M., Hamilton H, Rummens JA, Oxman-Martinez J,

Ogilvie L, Armstrong R, Humphrey C, (in press) Predictors of
Emotional Problems and Physical Aggression among Children
of Hong Kong Chinese, Mainland Chinese and Filipino Immi-
grants to Canada Social Psychiatry and Psychiatric
Epidemiology.

Hamilton HA, Marshall L, Rummens JA, Fenta H, Simich L.

(unpub. under review) Immigrant Parents Perceptions of School
Environment and Childrens Mental Health and Behaviour.

Reports

Canadian Task Force on Mental Health Issues Affecting Immi-

grants and Refugees. (1988). After the door has been opened
(Cat. No. Ci96 38/1988E). Ministry of Supply and Service,
Ottawa.

Citizenship and Immigration Canada, Facts and Figures (2006).

Immigration Overview: Permanent Residents, www.cic.gc.ca/
EnGLIsh/resources/statistics/facts2006/permanent/12.asp.

107
 Mental Health Promotion through
Empowerment and Community
Capacity Building among East
and Southeast Asian Immigrant
and Refugee Women
Yuk-Lin Renita Wong, PhD. is Associate Professor at the School of Social Work at York University. Her research interests include:
gender, migration and mental health; critical social work, spirituality and social justice, community-based action research, and
post-earthquake community rebuilding in Sichuan China.
Josephine P. Wong, RN, MScN, has been a public health consultant and researcher for seventeen years. She is Associate Professor at
the Daphne Cockwell School of Nursing at Ryerson University, and a doctoral candidate at the Dalla Lana School of Public Health at the
University of Toronto.
Kenneth P. Fung, MD FRCPC MSC, is Assistant Professor at the Department of Psychiatry at the University of Toronto and the Clinical
Director of the Asian Initiative in Mental Health (A.I.M.) at Toronto Western Hospital of the University Health Network, Toronto.

abstract
This article presents a demonstration project that used inclusive health promotion to address the mental health needs of East and
Southeast Asian immigrant and refugee women in Toronto. The project demonstrated that effective mental health promotion must
consider the social determinants of health, and integrate the principles of social inclusion, access and equity into practice.

Acknowledgements:
The authors gratefully acknowledge Mr Raymond Chung, who was the Executive Director of Hong Fook Mental Health Association in the
duration of this project, as well as the Prevention and Promotion team, for their dedication and professional support throughout this project.

Introduction
Migration stress has been identified as one of the other family members (Guruge and Collins 2008;
major determinants of immigrant mental health. As indi- Williams 2008; Zadeh, Geva and Rogers 2008).
viduals and families go through the transition of Canadas immigration patterns have changed signifi-
settlement, they are often faced with increased stress cantly since the 1970s. Over the past three decades, over half of
related to the demands of adjusting to a new way of living: all newcomers are from Asia; China, Hong Kong, Korea,
loss of family and social network (Stewart et al. 2008), loss Taiwan and Vietnam have been on the top ten source
of gainful employment and socio-economic status (Dean countries of immigrants.1 Studies have shown that Asian
and Wilkson 2009; Picot, Hou and Coulombe, 2008), immigrant and refugee women tend to have a much lower rate
changes in roles and intergenerational conflicts (Chuang, of health service utilization compared to their counter parts in
Su and Tamis-Lemonda 2009; Este and Tachble 2009) and general (Lee 2002; Li and Browne 2000; Tu et al. 1999). While
difficulties in social integration and accessing health and some researchers attribute this low health service utilization to
social care due to language and systemic barriers (Sabatier Asian cultural values, or health beliefs and practices (Chiu et
et al. 2008; Yee 2003 ). Immigrant and refugee women al. 2005; Gilbert et al. 2004; Tsang 2004), other studies
experience additional stress because they bear the extra highlight the systemic barriers for newcomers to access
burden of caring for their spouses, children, elders and services (Bottorff et al. 2004; Fung and Wong 2007).

108
 Mental Health Promotion through Empowerment and Community Capacity Building
among East and Southeast Asian Immigrant and Refugee Women

This article presents the processes and outcomes of a Advisory Committee with members from each
demonstration project that used inclusive health community was established to advise the project at every
promotion to address the mental health needs of East and stage. Furthermore, the project used an unconventional
Southeast Asian immigrant and refugee women in method to hire its staff. Recognizing that newcomers
Toronto. The project considered and incorporated the experienced systemic barriers to employment, the project
diverse and unique contexts of the six target communities made it a point to eliminate Canadian work experience
in its design and implementation. Consequently, the as a job requirement and hired five newcomer women. It
project demonstrated that effective mental health also hired three Canadian-born or 1.5-generation young
promotion must consider the social determinants of women who desired to connect to their cultural roots
health, and integrate the principles of social inclusion, through community work. Bringing a diverse project
access and equity into practice. team together facilitated cross-cultural exchange.

The Project Framework: Promoting Health Phase I Community Assessment:

through Collective Empowerment Doing Research With and Not For the Community
In 2001, the authors collaborated with an ethno- Effective health promotion starts from the perspec-
specific mental health agency (Hong Fook Mental Health tives and experience of the community members. Using
Association) to carry out an action research project mixed methods of focus groups, in-depth interviews
funded by the Ontario Womens Health Council (OWHC) and surveys, we conducted a community needs assess-
to identify the mental health needs of immigrant and ment to explore how women in the target communities
refugee women from Cambodia, Hong Kong, Korea, conceptualized mental health, experienced migration
Mainland China, Taiwan, and Vietnam, who lived in the and settlement, defined their mental health needs, and
Greater Toronto Area. The goals of the project were to managed their stress and health. A total of 22 interviews
promote mental health literacy among the women from with service providers (including spiritual leaders) of the
the six communities and support them to make informed six communities were conducted to gain a general
choices about their mental health needs and access to understanding of the historical, cultural and local
care. The project included two components: community systemic environment that the women of the target
assessment and peer-to-peer empowerment education. populations faced.
Recognizing that our mental health is influenced by The research respected community self-determina-
a myriad of socio-environmental factors beyond biology tion and exercised flexibility to enable the communities to
and genetics (Jackson 2004; Mawani 2008; World Health define their research questions and needs. For instance,
Organization 2001), this project used a comprehensive the Cambodian communities preferred to engage in KTE
empowerment approach to promote mental health among of previously completed research instead of engaging in a
women and their families in the six project communities. new research because of research fatigue. Similarly,
Empowerment refers to a social action process that community consultation with stakeholders suggested the
promotes participation of people, organizations and need to respect the distinct historical, political and
communities towards the goals of individual and cultural differences among the Taiwanese, Mainland
community control, political efficacy, improved quality of Chinese and Hong Kong Chinese communities; as a
life and social justice (Wallerstein 1992, 198). result, the project re-allocated its resources to meet the
unique needs of the three communities to ensure that all
Womens Holistic Health Promotion: the research and empowerment education activities were
Integration of Theory, Research and Practice conducted accordingly.
There is a growing impetus for evidence-based policy Fifty-four women, of 25 to 75 years of age of diverse
and practice in health promotion; however, most socioeconomic backgrounds, participated in the in-depth
knowledge translation and exchange (KTE) activities tend interviews sharing with us the challenges they faced, the
to privilege the interactions between researchers and strategies they used, and the resources they mobilized in
policy-makers (Mitten 2007); frontline service providers re-making their life in Canada. A total of 102 women, of
and users are seldom included in the KTE process. With 18 to 60 years of age, took part in 13 focus groups, where
funding support from the Ontario Womens Health women articulated their conceptions of mental health and
Council (OWHC), the Womens Holistic Health mental illness, as well as discussed factors that affected
Promotion Project was able to engage community and helped maintain their mental health. The women
members, service providers and organizations to take part participants diverse articulations of mental health chal-
in an action research and follow-up program design. To lenged the stereotypical characterizations of Asian
ensure that the project was inclusive, a Community women and the dominant Western views of mental

109
 Yuk-Lin Renita Wong, Josephine P. Wong and Kenneth P. Fung

health; they viewed mental health and its social determi- Fooks Intake Line were received over a period of 3
nants as inseparable (Wong and Tsang 2004). months immediately following the campaign; these calls
Developed in consultation with the Community represented a 67% increase in comparison to the calls
Advisory Committee, a community survey of 1,000 self- received over the 3 months before the campaign.
administered structured questionnaires was conducted to
identify the womens health status, and the relation 2) Peer Leadership Training and Peer-to-Peer Outreach
between their mental health beliefs and help-seeking The Womens Holistic Health Peer Leadership
behavior. Contrary to the common discourse that Training Program was developed based on adult learning
immigrant women are reluctant to access mental health theory and critical pedagogy (Freire 1971). It aimed to
care because of stigma associated with mental illness, the support the participants to identify their individual and
survey results showed that the most important factor collective strengths to overcome the cultural and systemic
predicting attitudes towards seeking professional help was barriers they encounter in their daily lives. In this context,
the womens perceived access to culturally appropriate empowerment is not about service providers giving power
services (Fung and Wong, 2007). to women in the community. Rather, it is about creating
opportunities for women to participate meaningfully
Phase II Participation as a Path to Empowerment within their communities and integrate into society at
Informed by the results of the community assess- large (Labonte 1994).
ment and guided by the framework of empowerment and Furthermore, the peer leadership training used a
capacity building, Phase II of the project emphasized train-the-trainer model, whereby the project staff went
the social determinants of mental health. It consisted of through an intensive course of training that consisted of
two key components: 1) health communication; and 10 sessions. Upon its completion, the project staff
2) empowerment education to promote health literacy, recruited women from their respective communities to
self-efficacy and collective empowerment. take part in the peer leadership project; they also applied
their new knowledge and skills to train more women to
1) Health Communication: Mental Health become peer leaders. The training program was free of
As Understanding charge and in return the women peer leadership course
The goal of the campaign was to raise awareness of graduates were encouraged and supported to do holistic
the mental health issues faced by women in the six health promotion outreach and education to other women
project communities and the mental health resources or families in their own cultural communities.
available to them. The campaign theme of Mental Two project manuals were developed for the leader-
Health as Understanding was identified from the ship training: 1) a training manual used by the project
preliminary findings of the focus groups and through staff to train the women peer leaders; and 2) a workshop
consultation with our Community Advisory Committee. manual used by the women peer leaders to facilitate
The Campaign included a 30-second Public Service discussion groups and workshops among their peers in
Announcement (PSA) on TV and radio, and other print the communities. The manuals covered a range of topics
media in the six target communities. The PSA captured derived from the research results and existing literature,
the following themes: including collective learning, migration and settlement
the challenges for newcomers to gain adequate employ- experience, womens identity and family relations, social
ment as they experience cultural, language and systemic determinants of health, effective communications, stress
barriers management, and collective actions to promote health.
financial hardship experienced by low-income immi- In April 2002, the first round of Womens Holistic
grant/refugee families in the settlement process; Health Peer Leadership Training program recruited over
relationship tension and conflicts related to re-negotia- 161 women from the six project communities to form
tion of gender roles in Canada; 11 peer leadership groups. Over a period of five months, a
intercultural and intergenerational differences within total of 127 women peer leaders completed the training
the family; and program These peer leaders were proactive in their peer
the challenges of sole parenting for women whose outreach; they collaborated with other community
partners have to work in Asia to support the family agencies and faith organizations to provide workshops
financially. and outreach activities on holistic health. Between July
As part of the Health Communication Campaign, a 2002 and March 2003, they conducted over 79 workshops
Holistic Health Infoline for Women was set up to provide and outreach activities, reaching 5,029 participants. They
information and referral in the five project languages. A also put together a collective book project, Beyond rice &
total of 236 calls to the Infoline and 552 calls to Hong noodlesOur stories, our journey, to share their migration

110
 Mental Health Promotion through Empowerment and Community Capacity Building
among East and Southeast Asian Immigrant and Refugee Women

stories and their strategies of maintaining health in the minant of health. This time, the agency also included men
midst of hardships.2 The women peer leaders commit- who were interested in the peer training.
ment and successes were celebrated at the Womens Before 2001, Hong Fook had a total of 50 volunteers
Holistic Health Peer Leadership Graduation Ceremony committed to community outreach and promotion. In
held in October 2002. 2003, Hong Fook integrated empowerment and capacity
In addition to the above collective actions, the building into its health promotion program. The agency has
women leaders also demonstrated increased self-efficacy since increased their pools of volunteers to more than 200
in political action beyond their cultural communities; for holistic health women and men peer leaders who do
example, during an advocacy campaign to Save Medi- outreach at the grassroots level to provide culturally appro-
care, the Korean peer leaders collected over 10,000 priate health information and to influence community
signatures from the Korean churches, street campaigns, attitude in reducing stigma about mental illness.
and from their social networks to present to the provin-
cial legislature. Towards the end of this pilot initiative, the Conclusion: Inclusive and Equitable Services
original peer leaders were supported to become co-facili- as Best Practices
tators in the training of new groups of peer leaders. This The peer leadership training and outreach initiative,
model provides leadership opportunities, skill building which started as a pilot project in 2001, has proven to be
and expansion of social support network. an effective and sustainable health promotion program.
Over the past eight years, project staff have reviewed and
Sustainability reflected on the processes and outcomes of this initiative
Sustainability of health promotion programs is a and shared this knowledge with researchers, service
well-recognized challenge among practitioners, adminis- providers and policy makers (Wong et al., 2002; Wong,
trators and policy-makers alike. Many innovative and 2003; Wong, Wong and Fung 2003; Wong, Wong & Yoo,
effective programs delivered by small agencies eventually 2009). Within the mental health field, there is a recent call
dissolve due to the lack of strategies and resources to for moving mental health promotion into the mainstream.
sustain these programs. Furthermore, there is not a clear The Hong Fook peer leadership training initiative has
definition of sustainability (St Leger 2005). To develop demonstrated that mental health promotion is achievable
sustainable programming, an organization must have a through the use of collective empowerment and capacity
clear definition of what constitutes sustainability and building as key strategies. More importantly, best
what are the necessary conditions. In the context of this practices are best only if they are relevant and effective.
project, sustainability means the agencys ability to To be effective, we must go beyond the popular discourses
continue the empowerment education and outreach of cultural competence and cultural sensitivity to
beyond the funding provided by the OWHC. Thus, integrate the principles of social justice, access and equity
program sustainability is dependent on other resources in into the research-policy-practice cycle to guide interven-
addition to funding, such as the programs fit with the tions at the grassroots, and mandates and directions
organizations mandate; its flexibility to be modified to within health organizations and public policy in the
meet the changing needs of the community; its ability to government sector, with the common goal of addressing
outreach to the intended clients, and the capacity of the the social determinants of mental health.
key stakeholders (Sheirer 2005).
Upon the completion of the pilot project, the peer
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UndercurrentsTraversing the Paths of Mental Health.
Keynote panel presentation paper at the Forum on Bridging
Policy, Research and Practice in Cross-cultural Mental Health
(November 14). Toronto: Hong Fook Mental Health Association.

World Health Organization. 2001. World Health Report 2001.

Mental health: New understanding, new hope. Geneva: World
Health Organization.

Yee, B. 2003. Asian mental health recoveryfollow-up to the

Asian Report. New Zealand: Mental Health Commission. Occa-
sional Paper, 3.

Zadeh, Z. Y., E. Geva and M. A. Rogers. 2008. The impact of

acculturation on the perception of academic achievement by
immigrant mothers and their children. School Psychology Inter-
national 29(1): 39-70.

footnotes
1
All information about the top ten source countries of immi-
grants to Canada since 1979 is retrieved from the annual
statistics tables provided by Citizenship and Immigration
Canada. Available online: http://www.cic.gc.ca, retrieved on
June 2, 2004.
2
Altogether, four project publications were published and made
available for service providers and women peer leaders. They
were: Womens Holistic Health Peer Leadership Training:
Training Manual; Embracing Our Body, Mind, and Spirit:
Holistic Health Promotion for Women: Community
Workshop Manual; Stress and Mental Health Pamphlet;
and Beyond Rice & NoodlesOur Stories, Our Journey:
Health Strategies of East and Southeast Asian Immigrant
Women. They are available from the Hong Fook Mental
Health Association Webstie, http://www.hongfook.ca/en/health
_info/OtherPublications.asp.

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 Working with Immigrant Women:
Guidelines for Mental Health
Professionals
Sepali Guruge, Ryerson University
Enid Collins, Ryerson University
Amy Bender, University of Toronto

Women may choose to migrate for a variety of Home-country circumstances notwithstanding,

reasons including economic incentives, family reunifica- there are common factors that immigrants face following
tion, and educational opportunities, as well as to escape migration that are associated with health status. Most of
from gender-based and/or political violence and to gain these have been recognized as social determinants of
more social independence (DeLaet1999). The numbers of health, and include income and social status, employment
women immigrants and refugees to Canada have and working conditions, physical and social environ-
increased over the years and the percentage of women ments, social networks, gender, culture, and access to
settling in as immigrants (and refugees whose claims have health services (Health Canada, 2002). Additional deter-
been approved to become permanent residents) is usually minants of mental health for immigrants include social
2 to 7% higher than that for men (Citizenship and Immi- isolation, language barriers, financial and employment
gration Canada [CIC] 2006). In addition, the number of constraints, role reversal, new intergenerational struggles,
women entering Canada as economic immigrants, in racism, and discrimination (Hyman & Guruge, 2006).
comparison to those entering as family class immigrants, Some of these aspects of the settlement process may be
is slowly increasing. This is partly due to the increase in dehumanizing and particularly stressful (Sandys, 1996).
the number of women arriving as skilled or professional For example, having to respond to repetitive questions
workers. Approximately half of refugees are women, and regarding experiences of violence and abuse in the context
women also comprise a significant proportion of illegal of immigration procedures, can have profound implica-
immigrants. These statistics call attention to the need for tions for mental health. Mental disorders such as
health sciences research specifically on the health of depression, anxiety disorders, and post-traumatic stress
women immigrants. disorder may be precipitated in part by repeated re-
Upon arrival in Canada, immigrants1 are generally in traumatizing experiences.
better health than those born in Canada (Chen, Ng Access to services is one determinant of health that
& Wilkins 1996a, 1996b; Parakulum, Krishnan & Odynak can be overlooked for its effects on mental health. While
1992). Factors related to immigration selection criteria there are many services that are intended to assist
(e.g., rigorous health screening) and the immigration newcomers during the post-migration period, the actual
process itself (e.g., healthier people tend to move more than experiences of accessing such services can be difficult.
those with a poor health status) have been associated with Practically navigating bureaucratic hurdles, completing
this healthy-immigrant effect. However, after 10 years in many application forms, or physically getting to various
Canada, immigrants are more likely to be in poorer health agencies that may not be in close geographical proximity
than their Canadian-born counterparts (Chen et al. 1996a, are some examples of this (Collins, Shakya, Guruge &
1996b; Hyman 2001; Vissandjee et al. 2003). The research Santos, 2008; Guruge & Humphreys, 2009). Additionally,
is less clear about the healthy immigrant effect in relation language barriers insidiously contribute to these difficul-
to mental health (Canadian Task Force on Mental Health ties. Sometimes volunteer or un-trained interpreters may
Affecting Immigrants and Refugees 1986; Hyman 2004; not translate/interpret accurately (Abraham & Rahman,
Mental Health Commission of Canada, 2009). One of the 2008), which may compromise situations involving
reasons for this lack of clarity is the limited health sciences government authorities such as immigration, child
research on mental health and illnesses of immigrants. welfare, and/or legal aid (Guruge, 2007). By extension,

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 Working with Immigrant Women: Guidelines for Mental Health Professionals

the stress of such circumstances may affect psycholog- actively participate in shaping their health and that of
ical and emotional wellbeing, and exacerbate existing their families, despite the post-migration challenges and
mental illnesses. barriers they face in Canada. Women are also engaged
Challenges of the post-migration context in Canada participants in various community activities and in orga-
persist for women specifically, even after the initial reset- nizations including schools, places of worship, and
tlement period. Material, social, and systemic challenges volunteer sectors to improve the health and wellbeing of
might include downward career mobility, immigration their communities. This is a testament to their strengths
requirements that restrict womens choices (e.g., when and resilience.
dealing with abusive employers or abusive husbands),
unsafe work conditions, and lack of social support for Implications for Research, Education,
raising children or caring for elderly family members. Practice, and Policy in Mental Health
While some of these concerns can be experienced by Migration experiences can have a negative impact on
Canadian-born women and/or immigrant men, mental health for both women and men; however,
immigrant women consistently experience most of these research on immigrant women has limited representation
challenges, and/or to a greater degree. For example, in health sciences literature. In order to address changes
immigrant women are disproportionately poorer than in mental health practice, there is a need to examine
Canadian-born women and men, as well as immigrant macro, meso and micro systems, to determine how
men (CIC 2006). Furthermore, immigrant women have to knowledge is generated, how practitioners are educated,
cope with these realities of daily life while navigating and how preventive and curative aspects of care happen
social systems, government bureaucracy, and new cultures at both the face-to-face relational level and within
in an unfamiliar setting and, perhaps, in an unfamiliar communities. In this final section, we present some
language. In the post-migration context women often recommendations, based on several chapters in our book,
experience changes in gender roles, are forced into low Working with Immigrant Women: Issues and Strategies for
paying jobs, and may have to work at home and in paid Mental Health Professionals, categorized according to
jobs without the support of extended family and/or future directions for research, education, practice, and
community (Baya, Simich & Bukhari, 2008). Also, policy in mental health.
violence may be precipitated by social conditions such as
isolation, changed gender roles, and possibly a clash of Research
cultural norms and intergenerational expectations While there have been considerable collaborative
regarding womens rights and responsibilities (Guruge, efforts in expanding mental health research on immigrant
Khanlou & Gastaldo, 2010). women, certain research questions still require answers.
Such post-migration contextual factors are indica- Broadly, how is womens mental health defined and under-
tions of the troubling influence of the social determinants stood? How do the social determinants of mental health
of immigrant womens health, which are reflected in the manifest in womens lives? How do perceptions of ones
growing body of literature addressing the topic (e.g., mental health differ for young girls, adolescent girls, adult
Oxman-Martinez, Abdool & Loiselle-Leonard, 2000; women, and older women? Specifically, how do immigrant
Vissandjee et al., 2001; Hyman 2002; Hyman & Guruge, womens mental health statuses change over time, and
2006). In addition, some women who migrate may have across countries? Are there current holistic interventions
lived through war, slavery, political violence (Tsang & for addressing womens mental health issues? What are
George, 1998) and violence at home (Guruge, Khanlou & some innovative strategies for addressing challenging
Gastaldo, 2010) in the pre-migration context. Such experi- aspects of the immigration experience that impact on
ences, whether as isolated encounters or long-standing mental health? How do health care professionals engage
relational situations, can intersect with the post-migration in diminishing the negative effects of post-migration
social determinants to affect womens mental health and determinants of womens mental health? Finally, within
exacerbate existing mental illnesses (Mawani, 2008). the area of mental disorders, what are the direct links
How immigrant women respond to and deal with between a particular social condition and the symptom-
these issues is unique to each womans situation and atology of specific disorders, and how does migration
position in society based on the intersections of such itself confound these?
aspects of identity as age, race, class, ethnicity, language, Limited empirical research exists on the mental
education, and sexual orientation, along with the health concerns of newcomer girls and female youth
economic, cultural, socio-political, historical, and (Berman & Jiwani, 2008), those who have been trafficked,
geographical contexts of their daily lives (Guruge & who are homeless/street-involved (Collins & Guruge,
Khanlou, 2004). Yet the majority of immigrant women 2008) , or lesbian, bi-sexual, or trans-gendered immigrant

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 Sepali Guruge, Enid Collins, AND Amy Bender

women (Doctor & Bazet, 2008). Little attention has been (1993) pointed out, educators who represent minority
focused on older womens health, both physical and groups are likely to bring experience that facilitates a
mental health, in the post-migration context (Guruge, critique of the dominant standpoint. Collaboration with
Kanthasamy, & Santos, 2008; Guruge & Kanthasamy, community agencies that reflect the changing needs of
2010). Research gaps also remain in such areas as the ethno-cultural and racialized groups ought to be a
intersections of immigrant experiences and homelessness, priority for clinical practicum experiences, where
addictions, and violence and trauma. The need for further students may have opportunities to learn from and work
work in the area of intimate partner violence in the post- with immigrant women who may staff and/or draw from
migration context is particularly highlighted by the these services. Additionally, all faculty members (from
limited number of health research publications on the senior tenured professors to contract teaching staff) ought
subject (Fong, 2010; Guruge, 2007; Hyman, Guruge, & to become familiar with and utilize the growing body of
Mason, 2008). Furthermore, we know little about the research on mental health and illnesses of immigrant
growing number of immigrants who are under-housed or women.
live on the street, and how experiences of violence in these
situations either contribute to or exacerbate mental Practice
illnesses. Finally, research approaches to understanding Mental health professionals in various practice
violence must widen to address the broader social condi- settings are in key positions to recognize the often
tions such as patriarchy, racism, and poverty. negative experiences of immigration and settlement on
Researchers must pay close attention to the theories mental health and illness. In particular, they must pay
and conceptual frameworks, and the methodologies that attention to the following questions: What forms of
they employ in their research to ensure that the work that trauma and violence have clients/patients encountered in
is done is collaborative, inclusive, and based on social the pre-migration contexts? How do these experiences
justice and equity. Developing and testing culturally influence womens ability to cope in their new environ-
appropriate multidimensional instruments to assess ment? What are their border-crossing experiences? What
stress, conflict, violence, and mental illness is critical are their post-migration experiences? How are these
(Guruge et al., 2007; Sidani, Guruge, Miranda, Ford- affecting their mental health? And what can be done to
Gilboe, & Varcoe, in press). In terms of research team intervene? What are the ways in which they cope with
composition, immigrant women themselves ought to be mental illnesses? What are the ways in which their access
included in the research process to strengthen their to care for mental illnesses can be improved?
awareness of their abilities and resources, strengthen the Service agencies that espouse a vision of mental
quality of the final product, and support womens efforts health promotion must implement programs and strate-
to mobilize for change and facilitate their input into gies that practically reflect a supportive environment for
policy and decision-making. cultivating womens strengths and resilience. For example,
programs could be organized to bring together women
Education and young children to share resources and experiences,
Mental health professionals in Canada are educated and build supports within their own communities. Mental
in a wide range of disciplines with each possessing its own health practitioners must also examine their own values,
professional culture and emphasizing specific areas of beliefs, powers, and privileges in order to identify how
knowledge and skills. In all of the health disciplines, actions in their practice support immigrant women and
education has developed primarily from the Western facilitate their resilience, or how the practitioners them-
medical model and reflects Canadian socio-political and selves and/or organizational structures create barriers and
cultural perspectives. This preparation does not reflect disadvantage for these clients/patients (Gustafson, 2008).
Canadas changing demographics, the significant presence
of immigrant groups, and the increasing numbers of Policy
women from diverse ethno-cultural groups who are It seems evident that governments at all levels must
consumers of mental health services. There is a pressing continue to provide appropriate funding support for new
need for education that accounts for and responds to immigrants arriving in Canada. The Task Force on Mental
these shifts to better prepare mental health professionals Health Issues Affecting Immigrants and Refugees (1986)
to respond appropriately to the needs of diverse groups. recommended that Health and Welfare Secretary of State
Such initiatives are possible only when administrators of and the Status of Women develop and provide multilin-
educational institutions commit resources to organiza- gual educational materials on womens rights and roles in
tional changes in faculty staffing and curricula that reflect Canada for discussion within immigrant services, general
diversity, inclusiveness, and capacity-building. As Sleeter community service agencies, and ethno-cultural agencies.

116
 Working with Immigrant Women: Guidelines for Mental Health Professionals

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footnotes
1
In this article we will use the term immigrant to capture those
not born in Canada who have come to Canada under the broad
immigration categories of business class, skilled-worker class,
and family class (CIC, 2002a),. We recognize that in general
immigrants often arrive in a country voluntarily and refugees
are forced to flee their home countries. More recently, of the
more than 200,000 immigrants and refugees who come to
Canada every year, half have been women. However, we also
recognize the problematic use of the term immigrant in
everyday discourse as including any woman who is seen by
others as an immigrant because of her skin colour, language,
dress, and/or socioeconomic status, even if she was born in
Canada.