Report of the Canadian Task Force on Mental Health Issues Affecting Immigrants and Refugees
1988

Background - Executive Summary - Chapter 1 - Chapter 2-6 - Chapter 7-9 - Chapter 10-11 - Chapter 12 Conclusion & Appendices

To begin life again in a new country, migrants need practical assistance, psychological support and personal stamina. Immigrants and refugees who do not speak the language of the host country, or who, because of race or ethnicity, become objects of discrimination, often need special help during re-settlement.

Migrants to Canada have several potential sources of assistance and support: relatives and friends, ethno-cultural community groups, and social and health services agencies. The amount and quality of support actually received from these potential sources has a direct bearing on mental health.

Both the research literature and submissions to the Task Force emphasize the psychosocial support provided by family as an important resource for promoting well-being and preventing emotional disorder. As the Family Service Association of Metropolitan Toronto put it, "The support of family members is invaluable in the resettlement process."

Definitions of "family" vary. In many cultures, close family includes people who, in Canada, are considered 'relatives" - cousins, aunts and uncles, nieces and nephews. In industrial societies like Canada, the intensity of the relationships between siblings and between parents and children diminishes over time. But in many societies, it retains its power even after siblings or children marry.

Regardless of age, members of the nuclear family parents and children - and extended family such as grandparents, uncles, aunts and cousins play important roles in each other's lives. Separation can create emotional, financial, or political vacuums. The Association for New Canadians cites three cases of wife abuse which "might not have become so bad ... if members of the extended family were in Canada with the immigrants.' In these cases, it seemed likely that the extended family would have provided emotional support and reinforced cultural norms. This would have created more constructive outlets for the dissipation of intrafamilial tensions than the physical violence which brought these cases to official attention. Migrants fortunate enough to have extended family with them benefit from a psychosocial resource which can make their adaptation to a new life easier, particularly during the early years of resettlement.

Persons who have been separated from family by events beyond their control - like many refugees, for example - are in a situation of double jeopardy; they are bereft of potentially important sources of support during a difficult time and worry about the welfare of family left behind. This can create stress leading to anxiety and depression.

As Figure 2.1 indicates, over 35 per cent of adults immigrating to Canada between 1978 and 1987 were either single, widowed, divorced or separated.

Reunification after separation may not lead to consistently positive results. Spouses separated for long periods may find readjustment difficult.

Nevertheless, even reunited couples can cope better with the stress of adaptation than single or separated immigrants (Submission: Ontario Welcome House). The University of British Columbia Refugee Resettlement study of 1300 Southeast Asian newcomers documented higher rates of depression and anxiety among single, separated, divorced or widowed persons than among those who were living with their spouses: those people who reunited with spouses or went on to marry during the two years of the study experienced improved mental health.

Friendships are also important, so much so that they may serve as substitutes for missing family relationships (Kurien, 1980). Such friendships most naturally occur between persons of the same ethnocultural group, but a number of submissions to the Task Force suggest that relationships between immigrants and host Canadians of various cultural backgrounds can also "greatly reduce the loneliness and social alienation often experienced by immigrants" (Submission: Kingston and District Immigrant Services).

Host and sponsorship programs have made it easier for refugees and immigrants to be admitted to Canada and to receive practical assistance during the early years of resettlement. While the importance of these programs is well recognized, the powerful influence that host and sponsor actions may have on immigrant mental health has not received sufficient attention. Studies have shown that pressure to adopt a sponsor's religion creates stress for grateful and dependent newcomers (Kitchener-Waterloo Council of Churches, 1988; Beiser, 1988). This stress may result in emotional disorder. Pressure from the hosts may not be overt or even conscious; sometimes it is grateful refugees perception that he or she is expected to convert that creates the stress, rather than anything the host has said or done.

Other situations also generate strew. Refugees often perceive their sponsors as being overly intrusive in their family lives, even though sponsors may believe they are only being helpful. Despite the potential problems, hosting and sponsorship can be potent forces in preventing emotional disorder. Some studies have demonstrated that sponsorships which turn into prolonged friendships benefit mental health.

Some of the Refugee Host Group programs of CEIC provide information to sensitize hosts to the needs and the culture of newcomers, but such information is needed to guide the generosity of all hosts as well as sponsors.

As the New Brunswick Multicultural Council noted, local ethnic communities not only provide a welcome in an unfamiliar land but also 'help to replace the lost familial and social networks so important to mental balance." Ethno-cultural communities provide some of the practical assistance and psychological support which extended families provide in traditional cultures and which service agencies provide in Canada.

Research has repeatedly demonstrated that immigrants and refugees who settle in an area where their ethnic group has already established a significant community experience lower levels of distress, and are much less likely to be hospitalized for mental disorder than migrants who do not have a Eke-ethnic community available to them. The psychosocial support provided by an ethnic community is particularly crucial during the early phases of resettlement.

The UBC Refugee Resettlement study compared rates of depression among ethnic Chinese refugees settling in Vancouver, which has a long established Chinese community, to Vietnamese and Laotian who had to establish their own cultural group on arrival. Vietnamese and Laotians experienced a risk of developing a depressive disorder three times greater than the Chinese (Beiser, 1988).

For the Southeast Asian people, community is the second most important social unit after the family. ne informal community supports to all members in everything they do is the! difference between Southeast Asian community support and the institutional support system.

(Submission.. S. E. A. P. C. O. M.)

An important feature of viable communities is the numerical balance between males and females. Some immigrant communities are characterized by a significant imbalance between the sexes. For example, almost twice as many men as women have emigrated from Ethiopia since 1980. During the same period, females from Jamaica consistently outnumbered males. The mental health implications of such " unnatural " communities vary depending on the marital status, cultural background and economic situation of the individuals involved. However, priority should be given to applications for family reunification made by members of unnatural or imbalanced communities.

While ethnic communities provide practical assistance to newcomers, research evidence suggests that they help to protect mental health mainly by affirming cultural and personal identity. Religious institutions, for instance, reinforce personal faith which can act as a buffer to stress (Submission: immigrant Women's Group of P.E.I.). Speaking one's mother tongue relieves the strain and exhaustion of constantly translating. Simple recreational and cultural activities enable immigrants to 'let go" and "be themselves".

Where viable ethnic communities do not exist, immigrants and service agencies may be particularly challenged by the problems of settlement and adaptation.

Encouraging and fostering self-help and community leadership are important initiatives. Within any ethno-cultural group there are individuals with leadership capabilities and, in some instances, these people emerge spontaneously to guide and counsel community members.

While leadership sometimes emerges naturally, it can also be fostered through training programs which encourage and utilize innate skills (Submission: Inter.-Church Committee for refugees). Many programs described in Chapter Six depend on the leadership of ethno-cultural group members.

The Multiculturalism Sector of the Department of the Secretary of State contributes positively to the formation of support systems, ethnic organizations and leadership by funding multicultural social programs, ethno-specific cultural activities, heritage language programs and visible minority cultural development projects. Federal funding in this area is flexible and generous, with special consideration given to immigrant women’s groups, children and youth. The Task Force encourages continuing funding of these programs, and urges that such support become more available to recent and less organized minority groups.

Canada's multiculturalism policy, which emphasizes opportunities for integration with the larger society as well as the enhancement of cultural heritage, endorses a principle and at the same time suggests actions important for mental health. While people from the same ethnic background often five in the same neighbourhoods, shop at the same stores, send their children to the same schools and attend the same churches because living together imparts a feeling of mutual support, this can, in the extreme, lead to isolation from the language, the institutions and the opportunities of the larger society. Isolation can in rum create a condition of risk for mental health. Programs to facilitate the development of ethnic communities should be developed hand-in-land with others which encourage interaction with all aspects of Canadian society.

Pre-migration orientation and settlement services can help to reduce stress and facilitate adaptation.

Pre-migration orientation is called for by immigrants, service agencies and government departments, as well as by the research literature.

Some efforts to provide pre-migration orientation are underway. A Polish-language videotape and brochure have been produced by CEIC in collaboration with Polish immigrants and distributed abroad for prospective Polish immigrants. A similar program for Central and South Americans is in the early stages of development. A pilot project in Thailand, funded by CEIC through the Mennonite Central Committee, provides orientation, language training and some skills training.

In addition to providing orientation materials in the languages of persons seeking immigration, CEIC is also encouraged to consider language skills when hiring, placing or transferring officers at home and abroad. Since CEIC officials are often the first Canadians that immigrants meet, it is particularly important that, regardless of language ability, they have enough cultural awareness and sensitivity to be fair - and to be perceived as fair - by the persons they interview. Cultural sensitivity training currently provided to officers should be evaluated by CEIC in collaboration with professionals from the fields of cross-cultural communications, adult education and immigrant settlement.

Immigrant settlement services constitute "a bridge to the mainstream or host society whose efforts deeply affect the settlement, adaptation and long-term participation of immigrants and refugees" in Canada (Submission: Alberta Association of Immigrant Serving Agencies).

The Task Force received numerous descriptions of the welcome, orientation, interpreting and advice provided by service agency staff, many of whom are immigrants themselves. As with ethno-cultural communities, immigrant service agencies also play a major role in providing support for people who develop mental health problems (Chapter Six). Their assistance during settlement, however, is immeasurably valuable in promoting mental health and well-being 'even for those who are functioning optimally in Canada" (Submission: Edmonton Immigrant Services Association).

Agencies and ethnic communities across Canada were unanimous in calling for increased recognition of settlement services.

Much of the funding for settlement services comes from CEIC's Immigrant Settlement and Adaptation Program (ISAP). Since fiscal year 1983/84, ISAP funding has increased from $3.14 million to $5.9 million. However, CEIC steadfastly refuses to provide direct "core" funding for the agencies which deliver the services. In one respect the distinction is academic; if ISAP withdrew its funds-for-services, a majority of immigrant service agencies would collapse. In another respect, however, the official CEIC policy has serious consequences. The time spent applying for and reporting about multiple, short-lived programs and the year-to-year anxiety about funding exact a wasteful toll on both staff and clients.

Table 2.1 documents funding for migrant services in the top five immigrant-receiving provinces for the year 1986. The Table documents gross inequities in spending to support immigrant services: from a high of $226 per immigrant in Manitoba to a low of $8.76 per immigrant in B.C. Some provinces, such as Alberta, work closely with the federal government to support settlement agencies. Other provinces, such as British Columbia, are outspokenly reluctant to fund services which, they argue, fall under federal jurisdiction. Contributions from municipal governments also vary depending on the number of immigrants in a dry and the number of immigrant-related problems brought to municipal attention. As one submission asserted, municipal funding tends to be remedial rather than preventive.

The question of exclusive ' jurisdiction versus federal-provincial cooperation has more than just political and short-term budgetary implications.

Cooperation between federal and provincial governments regarding settlement services promises better mental health for immigrants, and long-term savings for provincial ministries.

Provincial Immigrants Per Total Per

Dollars Received Immigrant Population Capita

(approx.) Expenditure Contribution

Manitoba $850,000 3,749 $ 226.73 1,071,232 $ .79

Quebec $2,500,000 19,475 $ 128.37 6,540,276 $ .38

Alberta $1,200,000 9,677 $ 124.00 2,375,278 $ .50

Ontario $4,700,000 49,663 $ 94.64 9,113,515 $ .52

B. C. $110,000 12,556 $8.76 2,889,207 $ .04

Adapted from Cultures West" (Newsletter of the Affiliation of Multicultural societies and Services Agencies of B. C.), 5(4):3.

Provincial health and social services have an important role to play in immigrant settlement and adaptation. The same should apply at the federal level. Health and Welfare, as well as CEIC and the Secretary of State, should assume responsibility for the well-being of newcomers. At the moment, Health and Welfare has limited involvement.

Health and Welfare Canada and its provincial counterparts could contribute to the health and well-being of newcomers in a number of ways. Those who have not received a Pre.-migration physical examination by a Health and Welfare physician should, upon arrival, be assessed by a physician. This initiative should be supported by appropriate government ministries. Psychosocial assessments, preferably carried out by qualified staff at immigrant service agencies and funded through Health and Welfare or appropriate provincial counterparts, should be carried out for all immigrants soon after arrival (Chapter Six). Medical and dental care for refugees should be extended to encompass more than the emergency and acute situations presently covered.

The sections on Remedial Measures and Special Needs suggest other ways in which Health and

Welfare could contribute to immigrant well-being.

Ensuring adequate and stable funding for immigrant service agencies, promoting prompt and inclusive family reunification, and providing effective pre-migration orientation are three of the most important ways to facilitate adaptation.

The central role of immigrant service agencies during resettlement must be recognized since unstable and insecure funding erode their effectiveness. The Task Force recommends that CEIC, Health and Welfare, and Secretary of State provide core funding to immigrant service agencies to guarantee their maintenance on a long-term basis. Core-funding for agencies should be tied to the number of immigrants already living in an area as well as to the number of new arrivals. Short-term funding should be available for pilot projects and specific services meeting short-term needs. The settlement services provided by immigrant service agencies can be cost-effectively supplemented by, for example, educating hosts and sponsors of refugees and immigrants about the resettlement process, or by extending the time period over which informal (non-monetary) support is provided.

Along with refugee status, family reunification must continue to be given the highest priority as grounds for admission to Canada. It is recommended that CEIC expedite changes in admission criteria to accommodate a broader definition of family, and changes in admission procedures to accelerate the process of family reunification. The financial criteria for co-sponsorship agreements should be assessed and consideration given to expanding the program.

Migrants with little or no family in Canada must not be forgotten. Programs in which immigrants and refugee with few relatives are matched with families of similar ethno-cultural background should be encouraged if such matching is consistent with migrants' wishes. Refugees could be directed to destinations where there are appropriate ethno-cultural communities. Where such communities do not exist, their development should be encouraged through the cultural maintenance programs currently funded by Secretary of State. These programs, particularly those focussing on leadership training, should be expanded. Hosting and co-sponsorship should be encouraged and monitored. Hosts and co-sponsors should receive appropriate orientation to the culture of the newcomers they are helping as well as to the experience of resettlement and how their actions may influence the new settlers' mental health. To perform their important task, hosts and co-sponsors may require guidance; back-up resources must be available for this purpose.

Pre-migration orientation represents a relatively new idea, perhaps even a "high-risk, high-potential" venture. Much of the orienting done by im service agencies could be simplified and the time spent in counselling immigrants experiencing stress due to acculturation could be reduced if pre-migration orientation were offered. The Task Force recommends, therefore, that CEIC develop a multilingual series of Pre-Migration orientation programs in collaboration with immigrant Service agencies and ethno-cultural organizations for dissemination in refugee camps and at Canadian embassies abroad. Topics addressed should include employment, housing, schooling, climate, language training, psychological adaptation and social and cultural relations.

Without language, one can never truly enter a culture.

More than 30 presentations to the Task Force dealt with problems arising from lack of language proficiency. "It is the sense of being a 'marginal' person in society rather than a fully participating individual that directly contributes to a great number of health and social problems" (Submission: Immigrant Women's Association of Manitoba, Inc.).

Besides the isolation and loneliness it imposes, lack of language has indirect effects on mental health. Settlers in Canada who cannot speak English or French are less likely to find employment than those who do (Chapter Four). Newcomers who, despite their language handicap, succeed in finding a job, are likely to be underemployed, working at a level below that expected of persons with their level of training. Both unemployment and underemployment are risk factors for mental health.

Migrants who lack language proficiency suffer double jeopardy. While more likely to develop mental health problems than their English- or

French-speaking counterparts, they also derive less benefit from the mental health care system (Chapter Five). They are less likely to make use of mental health services and, if they do seek treatment, are more likely to terminate prematurely or to experience an unsatisfactory outcome.

While many language programs exist for immigrants and refugees, restrictive criteria prevent some people from participating. Other problems, including inflexible class scheduling and funding instability, militate against the potential contribution of these programs.

During the past decade, an average of 43 per cent of all immigrants arriving in Canada in a given year have spoken neither English nor French.

As illustrated in Figure 3.1, refugees are less likely to speak one of Canada's official languages than family class or independent immigrants. On the whole, more women than men arrive in Canada speaking neither English nor French.

The extent of the problem varies from province to province. More than half the immigrants destined for Manitoba between 1979 and 1986 had no capacity in English or French (Consultation: Manitoba Provincial Immigration and Settlement).

While, on average, the proportion of non-English speakers has tended to remain constant among arrivals to Canada, it has steadily increased in Alberta.

The British North America Act defines education as a provincial matter. Federal responsibility for immigrant language training is, therefore, discharged through federal/provincial arrangements.

Federally funded language training programs for immigrants (ESL/FSL - English as a Second Language/French as a Second Language) are presently administered by the Department of the Secretary of State and CEIC.

1. CEIC Labour Market Access Language Training

Under the job Entry component of the Canadian Job Strategy, CEIC provides language training for adult migrants and native Canadians who cannot find employment in their usual or related occupations due to a lack of proficiency in one of the official languages.

Training seats constitute the basic mechanism through which the federal government provides for language instruction. The federal government purchases training seats from the provinces and from private institutions according to priorities set by needs assessment committees. Language instruction is then provided by instructors hired by the provinces. Training is usually full time; basic living allowances or unemployment insurance benefits are provided to trainees who meet certain criteria. Members of the Family Class and Assisted Relatives, while eligible for training, do not receive the basic training allowance. They can, however, receive supplementary allowances for child care, living away from home expenses, and community expenses.

In response to the large refugee movements of recent years, the scope of language training has increased. In 1978, there were 2,000 training seats; in 1987, more than 14,000. Eligibility criteria have also expanded to include unskilled workers who are unable to secure employment or to undertake vocational training without language training.

2. CEIC Skills Language Training

Certain projects for immigrants, funded under the Job Entry, job Re-entry, and Job Development programs of the CEIC, also provide a component of language education. This type of language training is not considered an alternative to full-time training; it is seen as an adjunct for immigrants who must achieve a higher level of fluency or who need a good working knowledge of a specific occupational terminology.

3. CEIC settlement Language Training

In 1986/87, CEIC funded the Settlement Language Training Program (SLTP), a pilot project designed to meet the needs of adult immigrants primarily women - who are not destined for the labour force. The program format was flexible; onsite child care was available and out-of-pocket expenses were reimbursed where need was indicated. SLTP funding has again been allocated for 1987/88, but only at the pilot project level of $1 million.

4. Secretary of State Citizenship and Language Training (CILT)

With the exception of New Brunswick, all provinces and both territories have signed Citizenship and Language Training (CILT) agreements with the federal government. Under CILT agreements, Secretary of State pays half the salaries of instructors engaged in language training for individuals intending to acquire citizenship. Training is part time and no allowances are provided. In addition, Secretary of State reimburses provinces up to 100 per cent of the costs they incur for printed materials used in language training.

5. Secretary of State Citizenship and Community Participation Program (CCPP)

Some language instruction is included in the Citizenship and Community Participation Program

(CCPP) funded by Secretary of State. CCPC replaces the Cultural Integration Program once funded by the Multiculturalism Directorate.

Restrictive eligibility criteria constitutes the most serious limitation of federally funded language training programs.

Since current policy dictates a focus on migrants destined for the labour market, many immigrant women and seniors are cut off from language training programs, particularly those falling under the Canadian job Strategy initiative. In 1986, 87 per cent of immigrant men, but only 49 per cent or immigrant woman, were identified as labour-force bound and thereby eligible for CJS training

allowances.

The SLTP pilot project, aimed at meeting the language needs of non-workers, has had very positive results, particularly among immigrant women. As the Association for New Canadians reported, SLTP offers "invaluable assistance" for those immigrants who will not be entering the work force, but who must have a functional grasp of the language they hear all around them.

Inadequate and inconsistent assessment and referral practices plague language training programs, even for those immigrants who are eligible for them.

Migrants' personal backgrounds, learning goals and settlement needs are frequently overlooked during assessment. Course placements are often made by officials who cannot communicate with the clients, yet the complexity of the training options (different entrance requirements, non-standardized criteria for transfers) make it virtually impossible for immigrants to plan their education themselves.

The assistance and advice immigrants receive appears to vary from region to region and, in some cases, from counsellor to counsellor. Access to language training may or may not be restricted to one family member. Unemployed immigrants may or may not be advised that they need to speak English or French in order to find 'suitable' employment.

Language training must be preceded by professional, holistic assessment and individual client

counselling. The Teachers of English as a Second Language (TESL Canada, 1982) have recommended the establishment or counselling centres where sensitive assessments and consistent, fully informed referrals can be made. Catholic Social Services of Edmonton and Calgary Immigrant Aid, both provincially funded language and vocational assessment centres, provide valuable models for implementing this recommendation.

Lack of coordination in program planning has resulted in an inefficient and sometimes wasteful use of resources. While some programs are forced to turn away eligible applicants, other language training components are under-utilized.

Language training is delivered in a myriad of formats, ranging from full-time institutionalized programs of 36 weeks to volunteer classes or home tutoring of relatively short duration. Program

content is just as varied, depending as it does on the funding source, the clientele for which it was originally developed and the individual instructor.

The problem is not with program variation per se, but that is usually lacks overall planning and

purpose. In fact, there is a need for even greater flexibility in program format and content, but flexibility which responds to the educational background, situational needs and personal aspirations of the clientele:

C The time and location of classes must be flexible, whether morning, evening or during the lunch hour at the workplace.

C Existing vocational training programs could be enhanced by CEIC and relevant provincial ministries by incorporating language training components.

C There should also be a 'cross fertilization of purpose' in all training, for example, ESL/FSL could be incorporated with the teaching of parenting or lifeskills.

C Language training programs must be flexible in the level of language difficulty; for example, instruction could range from basic "survival language " for newcomers during early phases of resettlement to more advanced language training for professions.

The province of Quebec's language-training tracks, which are tailored to meet individual needs and goals, provide a valuable model which might he emulated elsewhere.

The federal government must ultimately take more responsibility for ensuring the efficacy of the language training programs it funds.

By assuming or delegating a coordinating role, the federal government could ensure that existing language training opportunities are fully utilized, that successful, innovative program ideas are shared among institutions serving similar populations, and that the dollars expended on language training result in language acquisition.

Instability in funding makes it extremely difficult for program administrators to attract, develop and retain qualified staff.

Depending on the funding, instructors delivering language training vary from persons without formal qualifications to those with post-graduate degrees in education. Programs with relatively stable, adequate funding naturally attract better qualified instructors. More importantly, these instructors remain and pass on to clients the benefits of first-hand experience and skills learned on the job.

As several submissions noted, skills learned by teachers on the job are critical for the adaptation

and integration of their students.

Qualifications of Language Instructors: Because they are respected persons who come into contact with migrants during the early phases of resettlement, ESL/FSL teachers are sometimes looked to as counsellors and advisers as well as language instructors. They are, therefore, in a good position to identify migrants who are at risk for developing emotional disorder.

Before ESL/FSL teachers can perform their principal task, imparting language, in an optional fashion, let alone adding the new responsibility of acting as gatekeepers for mental health, a number of steps must be taken. Teachers should receive formal accreditation and recognition commensurate with their qualifications and experience. Standards should be established by provincial ministries responsible for education with the encouragement of CEIC and Secretary of state. ESL/FSL teachers should be trained to identify signs of emotional distress and how to make appropriate referrals. Mental health consultation must be available on an ongoing basis.

Stable funding must be provided to enhance the efficacy of language training by enabling administrators as well as instructors to improve programs on the basis of experience. At present, evaluations of many language programs are never utilized because the programs themselves are so short-lived.

Finally, with dependable funding, meaningful research can be undertaken and the results fed back into the programs on which they are based. Such questions as how to best reach job-specific language, or how persons illiterate in their mother tongue can best learn a second language, need to be answered by empirical data derived from stable language training programs.

All immigrants should have equal access to official language education according to need, so they can integrate with and contribute to Canadian society.

It is recommended that CEIC enable all immigrants and refugees to have equal access to official language education whether or not they are destined for the labour market.

Basic training allowances must be available regardless of the immigration class of training applicants.

The number of training seats purchased in each province should be commensurate with longstanding needs of immigrants as well as with current levels of immigration.

Flexible arrangements should be available to ensure appropriate care of children while parents are attending language training programs.

There is also a need for the programs themselves to be varied in scope and format.

The Task Force recommends that CEIC, in coordination with Secretary of State, expand and ensure the flexibility of official language training programs with respect to the level of mastery assumed, objectives of course content, duration of program, scheduling of instructional hours and location of classes.

People work in order to make a living. However, in an achievement-oriented society such as Canada's, work also possesses important symbolic value: being a person of worth depends on being a productive, contributing member of society. Because self-esteem, the way we sec ourselves, is a reflection of the way we are perceived by others, people who do not or cannot work often feel unworthy. This threat to self-esteem makes people vulnerable to developing emotional disorder. Increased rates of depression, alcoholism and suicide during periods of economic recession or among people who lose their jobs because of local economic dislocations are powerful evidence of the damaging psychological effect of unemployment. Unemployment affects other people besides the one who cannot find a job. Families in which the head of the household is unemployed suffer an increased frequency of child abuse, wife-battering and marriage breakdown.

Although unemployment poses a risk of psychological problems for everyone, immigrants and refugees are particularly vulnerable to this stressor. Changes in Canada's migration patterns have affected immigrants' participation in the labour force. Where this country once drew upon the United Kingdom, the United States and European countries for its labour needs, more recent waves of immigrants and refugees have brought workers from Asia, Africa, and Latin America (sec Figure 0.3). Suitable entry to the labour force for this "new" immigrant is frequently delayed due to lack of training or work experience appropriate to the Canadian labour market. Typically the last to be hired and first to be fired, migrants suffer higher rates of unemployment than the general population. Barred from many jobs because of language difficulties, lack of training or discrimination in hiring practices, many migrants are forced into low-level jobs in which their marginal status makes them prone to exploitation. Highly educated and highly trained immigrants and refugees often find it impossible to work at the level for which their training has prepared them; the resulting underemployment is a potent risk factor for emotional disorder.

Besides the emotional suffering experienced by immigrants and refugees as a result of unemployment and underemployment, the host country is penalized. People who could and should become important resources for Canada must, too often, turn to public assistance. They also resort to the health care system because their marginal status damages their physical and emotional health.

Unemployment, underemployment and job insecurity create chronic stress for many immigrants, particularly during periods of economic down-tum. Certain categories of immigrants are further disadvantaged in their struggle for employment because of their race, sex or age.

"Visible minority" immigrants, those whose racial features distinguish them from the majority of

Canadians, experience the same discriminatory hiring practices that place Canadian-born visible minorities at a disadvantage in the job market. Measures to address racially based inequities and eliminate discrimination in the workplace are described in Toward Equality (1986), the response to the report of the Parliamentary Committee on Equality Rights, and also in the Abella Report (1982).

Immigrant youth often face obstacles to employment that go beyond those faced by either Canadian-born youth or by immigrant adults. Chapter Nine discusses the implications of disrupted schooling and language disability for the employment prospects of immigrant adolescents.

Immigrant women are not only subject to the inequities affecting Canadian-born women in the labour force; many are also destined to marginal employment because they enter the country as Family Class members and are, therefore, considered by many employment counsellors to have had little or no work experience outside the home. The implications of this status for employment opportunities and hence for the mental health of immigrant women are discussed in Chapter Ten.

Older immigrants who do not have jobs waiting for them are less likely to find employment than are younger adult immigrants or Canadian-born persons of similar age. Since increased age also affects ability to learn a new language or adapt to a new culture, older immigrants, as noted in Chapter Eleven, are vulnerable to stress-related health and mental health problems.

A disproportionate number of migrants who enter the work force do so through marginal types of employment, where standards and benefits vary considerably, Knowing little or nothing about Canadian law and often fearing that being fired means being deported, newcomers are vulnerable to exploitation.

Migrants who work as domestics or farm workers, for example, may be required to work longer hours and under more adverse conditions than would be tolerated in regulated industries, often for below minimum wage compensation. They are loathe to complain because they fear losing their jobs. Even if they were willing to complain, there frequently are no regulatory bodies to which they could appeal.

Immigrants working in high-risk industries such as mining and certain types of manufacturing may be in more jeopardy than their fellow Canadian workers because they do not fully understand safety instructions. Warning signs may be posted only in English and/or French. The implications of physical injury for mental health are obvious, and are compounded for many immigrants who are unaware of, or who cannot negotiate, the bureaucracy of workers' compensation.

There is a need for CEIC, in liaison with provincial ministries of labour, to review employment standards, occupational health and safety, and complaint procedures for domestic workers, farm workers and other occupations which employ immigrants and refugees.

Since, to a great extent, Canada's labour market needs dictate its immigration policies, persons who have been selected for immigration arrive with the expectation that they will be able to practise the occupation in which they have training and experience. Failure to realize these expectations results in frustration, alienation from a familiar working environment, erosion of skills and ultimate loss of human potential to the Canadian economy. In fact, occupational adaptation may well be more significant for mental health outcome than economic adaptation.

Canada can potentially benefit from an influx of people who have already been educated elsewhere. As Figure 4.1 illustrates, during the past decade, a third or more of all migrants to this country have been people with post-secondary educations. Unfortunately, many cannot or do not find employment at a level for which their education has equipped them. The negative impact of unfulfilled occupational expectations upon individuals with higher education or with technical or professional training was emphasized in numerous submissions.

Sexual stereotypes continue to make employment a particularly difficult problem for women.

The Calgary Catholic Immigration Society expressed concern about the psychological stresses their immigrant and refugee clients suffered because of lost social and occupational status. Immigrants and refugees with technical training who fail to achieve employment parity were found to be particularly vulnerable to the stress of unemployment. Difficulties with failure to achieve satisfactory employment due to licensing barriers were described by the Immigrant Women's Group of P.E.I., who raised the question of whether Canadian licensing bodies over-emphasize licensing regulations.

An intensive review of entry requirements to trades and professions was undertaken recently under the auspices of the Cabinet Committee on Race Relations, Province of Ontario (1987). This review attempted to identify the reasons why so many immigrants are unable to practise their chosen professions. While emphasizing the tentative nature of the findings, the authors suggested that systemic barriers with economic, cultural and administrative origins may have a disproportionate impact upon immigrants seeking entry to trades and professions in Ontario.

Among the more common barriers to access to trades and professions were:

1. Language proficiency

Lack of access to language training, inappropriate training modules, and lack of access to specific technical or professional language training have all been cited as obstructions.

The commonly used Test of English as a Foreign Language (based upon U.S. 1951 standards) has been challenged as being too stringent. Critics contend that the test over-emphasizes formal grammar while failing to place enough stress on proficiency in occupationally specific technical language.

2. Evaluation of academic credentials

Impartial evaluation of the credentials of foreign-trained immigrants is difficult to achieve. Evaluations are inevitably prey to subjectivity, hence to possible biases and to lack of understanding about educational equivalencies on the part of professional review panels. There is an ever-present danger that, in evaluating academic qualifications, professional societies may be moved to protect the interests of their current membership more than by the need to ensure parity. The result is that many migrants experience down-grading of their credentials.

3. Allocation of credit for foreign experience

Many trades and professions require proof of "Canadian experience' as an entry to practise. This places the foreign-trained in the difficult situation of not having the required experience yet being unable to secure employment where they might acquire it.

Discounting previous foreign experience due to lack of a certificate is a perceived barrier. Many foreign trained skilled tradesmen are schooled under the apprenticeship system in countries that pay little attention to certification. Inability to produce documentation to support experience is a deterrent to entry to some trades.

4. Examinations

The number of times an applicant may write an exam is often limited. Some professions - nursing, accounting, law - do not permit those who have trained abroad to write certification exams until they have taken re-training. This poses economic and social difficulties. For many newcomers, the cost of re-training may be prohibitive. Mature practitioners who do gain access to training programs may be inappropriately placed with young, first-time learners in structured learning situations to which they have difficulty adjusting.

5. Systemic discrimination

Immigrants have alleged that the barriers preventing them from practising their trade or profession were deliberately created to exclude foreign-trained personnel. Others perceived discriminatory practices as being cultural or racist in origin.

6. Translation and interpreter services

The poor quality of translation of documents has been cited as one reason equivalencies are sometimes not granted. The lack of translation and interpreter services are viewed as barriers to access.

7. Practical Considerations

Many immigrants, particularly refugees, complain about the requirements for presenting original documents. Refugees may have lost their documents in flight or in refugee camps. Political upheaval in their home country may mean there is nowhere to appeal for replacements. Some foreign schools may no longer exist, may be difficult to locate, or may be uncooperative in responding to requests for transcripts. Many immigrants are frustrated by the delays and costs involved in acquiring papers by applying to their country of origin. Given all these difficulties, it is small wonder that many migrants who are fortunate enough to have documents are reluctant to surrender original copies to Canadian accreditation bodies.

In sum, criteria for qualifications for entry to trades and professions are established to set standards, regulate practices and balance the rate of entry to training with that of labour market needs. The regulatory practices of trade and professional organizations, based on Canadian educational and training standards, do not accommodate foreign-trained persons. Migrants whose educational backgrounds do not exactly match those of Canadian norms may require special consideration in order to qualify for certification or licensure in their intended occupations.

Before immigrants can qualify to practise their trade or profession, they must have access to training programs. Criteria for admission to these programs can be as restrictive as those of the trades and professions themselves. CEIC, in cooperation with the provincial ministries of education and of higher education, should work closely with training institutions to encourage more flexible and broader criteria for admission to training programs.

Adjudicating the credentials of foreign-trained persons is vulnerable to bias due to the subjectivity of the process employed. However, in the absence of more objective evaluative criteria and general lack of information about the relative equivalencies of foreign educational systems, discrepant decisions made on the part of professional organizations with respect to the applications of immigrants are not subject to challenge.

For those who persevere beyond the entry process, delays in obtaining equivalencies, requirements for re-training, demonstration of "Canadian experience, " and financial considerations unreasonably extend the process. Prolonged alienation from the respective occupational environment leads to erosion of skills, loss of technical idiom and diminishing confidence in one's capabilities - all serving to widen the gap between the individual and attainment of his or her occupational goals.

Some recent governmental initiatives to address the needs of specific groups of immigrants and refugees have had notably successful results. In Quebec, the Division scolaire et profcssionelle of the Ministers des communautes culturelles et de l'immigration was concerned about the manpower wastage resulting from underemployment, and the psychological stress this creates for migrants not working at their level of achievement. Under its reorientation program, the division performs a number of functions for individual migrants including determining the North American equivalence of their diplomas, and arranging for special training that leads to up-grading and relicensure. During their training, migrants may receive financial support from the Ministry.

Under Canadian Job Strategies Initiatives, approval has been given for the production of 26 half-hour television instructional segments in basic English under the joint sponsorship of CEIC and Secretary of state. It is hoped that the success of this project in Ontario will lead to similar programs being developed elsewhere in Canada.

The Task Force heard one particularly innovative suggestion: that CEIC consider providing a subsidy to employers to promote the hiring of one additional employee to offset an equivalent number of man-hours allocated to "on the job" language training for immigrants and refugees. An administrative fee associated with allied costs might serve as further incentive to employers to take advantage of such a pilot project. The net effect would be to generate employment both for the unemployed segment of the Canadian labour force and that of newcomers.

Sooner or later, most newcomers come into contact with an employment counsellor. Too often, these are unhappy experiences resulting in demoralization and lowered self-esteem. Migrants applying for job assistance are particularly vulnerable; they may interpret a brusque manner, a culturally insensitive remark, an offhand acknowledgement of some skill they have worked hard to achieve, as rejection of themselves and as evidence of racism. They are undoubtedly correct some of the time.

There is a need for the current cross-cultural orientation programs for employment counsellors to be thoroughly evaluated. This project should be undertaken in collaboration with professionals from the fields of cross-cultural communication, adult education and immigrant settlement. The evaluation should include measures of effectiveness, knowledge of course content and acquisition of culturally sensitive attitudes and behaviour. Performance appraisals should include these criteria.

CEIC should explore means of recruiting employment counsellors from ethnic communities. Heritage language ability and cultural sensitivity should be seen as assets in hiring decisions. These abilities should be taken into greater consideration when placing and transferring counsellors.

Canada's immigration policy is in part dictated by a motivation to admit well-trained, well-educated people who can contribute to our economy. If we admit people according to this principle, but fail to provide opportunities for them to exercise their skills, the result is a disservice both to individual and national interests. The process is wasteful of human talent and it may jeopardize mental health.

The Task Force recommends, therefore, that CEIC, Ministry of Labour and Secretary of State enter into negotiations with their provincial counterparts to provide criteria and guidelines for entry into professions and trades by persons trained outside of Canada.

Incentives to the private sector should be provided by CEIC for more immigrant and refugee on-the-job training positions, tied to employment equity programs. Equal employment opportunity policies in both private and public sectors should be promoted by Treasury Board in coordination with CEIC and Secretary of state. Information about existing policies and programs should be distributed.

Chapter 5. Formal Mental Health Care

Chapter 6. Mental Health Care

Outside the Formal Network

Chapter 7. Training for Service Providers

Chapter 8. Ethnic Practitioners

The mental health care system in Canada is a loose amalgam of services of two types: 1) those mandated to deliver mental health care and 2) those which, although organized for a different purpose, treat and rehabilitate people with mental disorders. The formal mental health care network is made up of mandated services: psychiatric hospitals, psychiatric wards in general hospitals, clinics, community mental health agencies, and mental health practitioners in private practice.

Other agencies also deliver mental health care, even though this may not be acknowledged or recognized by either the institution or its clients. People who are troubled often avoid formal mental health services, turning instead to family physicians or to family service counsellors, public health nurses, the staff of multicultural or ethnic community organizations, or second-language teachers. For example, of all contacts between majority culture patients and family physicians, 15 to 20 per cent involve a mental health problem. Although no data about the way immigrants and refugees use the health care system have appeared, there is no reason to believe that the proportion of time and effort taken up by psychiatric problems is any less than it is among the majority of Canadians. In this section, we refer to this de facto system of mental health care as mental health care outside the formal network.

Immigrants and refugees experience stress if they have suffered trauma before migration, or if, after migrating, their needs for social support, language capability, and meaningful employment have not been met. When this stress is combined with certain personal characteristics, emotional problems may result. Many migrants are reluctant to use formal mental health services, sometimes because of the stigma of mental disorder and some times because they doubt the benefits of treatments they cannot understand. If they do become clients, they are often dissatisfied with the treatment or terminate it prematurely. For example, 30 per cent of the people seen at mental health clinics drop out after the first interview; the corresponding figure for ethnic minorities is 50 per cent (Sue, 1977). The most common complaint is that mental health therapists do not provide culturally and linguistically appropriate treatment.

Immigrants and refugees often feel more comfortable with a worker from an ethnic organization someone who speaks their language and shares their culture - or with an immigrant services worker with whom it may be possible to discuss problems without being labelled mentally ill. However, people who have been trained to help migrants find shelter and jobs, to learn one of the official languages, or to provide prenatal and well-baby care, are not mental health care providers. Their training has not prepared them to recognize mental health problems or how to deal with them.

Barriers to access and dissatisfaction with formal mental health care as well as the lack of expertise in the de facto care system result in tension between the two sectors of care which is difficult to resolve. Ideally, the strengths and weaknesses of each should be complementary. There are examples of effective integration which leads to improved care. However, the examples are isolated ones. In general, the formal and dc facto sectors of care function in relative isolation from each other, rather than as components of an over-all system of care.

This section addresses questions and concerns about mental health care, staffing, and training. How can treatment be made more sensitive to the needs of newcomers and members of ethnic minorities? Should ethnic workers join the personnel of formal treatment agencies or is it preferable to attach mental health professionals to ethnic and/or community service organizations? Why are most immigrants and refugees so dissatisfied with the treatment they receive? Is the present non-comprehensive, non-integrated, non-system the best we can hope for? Or is it possible to develop new, more effective models for delivering services?

Concerns about the mental health service system include: the kinds of services that should be delivered; who should be trained to deliver these services; and what training should consist of. There are no easy answers. People who deliver specialized services for newcomers cannot become experts in diagnosing and treating mental illness, just as psychiatrists, psychologists, psychiatric nurses, and social workers cannot become experts in the cultures of all their clients.

The problem of combining cultural.1 and linguistic knowledge with appropriate professional expertise is so acute that failure to make use of people who combine these skills is a waste of resources. The Task Force frequently heard about immigrant and refugee mental health professionals who, because of licensure and practice restrictions, may never be able to utilize their skills in Canada, and about immigration policies which restrict the flow of such personnel into Canada.

Fortunately, the Task Force also heard other messages: about experimental models for providing care which seem to be working; training programs to develop personnel who may help knit the disparate strands of mental health services into a better system of care; and ways to case the frustration and overcome the loss to society of underemployed professionals.

At most, only 20 per cent of people with mental disorders who need care actually receive it somewhere in the formal mental health system. While underutilization of services is a general problem, immigrants and refugees resist mental health care even more than majority culture Canadians. Ethnic groups in Canada avoid the mental health system because they Feel that barriers impeding access to appropriate services are often insurmountable. They also feel that, even if they sometimes succeed in overcoming barriers, the treatment they receive is inappropriate or ineffective. These feelings are not confined to small communities or to recent arrivals. Large cultural groups who have been in Canada for generations also feel disenfranchised from care.

While symptoms of emotional disorder are remarkably similar throughout cultural groups, culture dictates how people perceive and respond to them. For example, depression is one of the most common of all emotional disorders and one of the most debilitating. Depending on cultural background, a person suffering from depression may try to ignore it, accept his or her suffering as fate, talk to a religious leader, seek treatment from a folk healer, discuss the problem with family, or consult a family physician.

Primary care physicians are an important community resource for treating persons with emotional problems or referring them to the mental health care system. However, their effectiveness is compromised by cultural factors. Even though primary care physicians help many persons suffering a depressive disorder, they fail to recognize these illnesses in as many as two-thirds of their patients. The problem is even more acute among their ethnic clientele. One reason is that people - knowingly or unknowingly - conceal their symptoms. In Asian cultures, it is unacceptable to complain to a doctor about feeling despondent, lonely, or suicidal. Chinese, Vietnamese, Laotian and Cambodian patients will concentrate instead on the physical symptoms of depression such as sleeplessness, weight loss, appetite disturbance and pain, all of which are considered more legitimate reasons to seek medical help. The result may be a misdiagnosis or a missed opportunity to refer someone for mental health care.

Even when a referral is recommended, people are reluctant to comply. Feelings of shame and fear of being stigmatized are potent reasons for resisting referrals.

Lack of information and misinformation about services also account for underutilization. A common fear is that one's immigration status can be jeopardized if he or she is found to have psychological problems.

Inability to pay is another barrier to getting needed help.

Part of the difficulty in getting people into appropriate care may stem from the extreme specialization which characterizes Canadian society, where mental health services are separate from other aspects of life, including general medical care.

Better mental health care programs for immigrants and refugees do exist. The American Psychiatric Association recently awarded a gold medal for innovative service to a successful mental health service for Indo-Chinese refugees, operating for a number of years in Portland, Oregon. Close integration of the mental health clinic with a community centre for Southeast Asian refugees undoubtedly accounts in part for the creation of large clientele. Refugees enter the treatment system with an ease which belies the stereotype that Asians resist mental health care, no matter how necessary it might be.

Hospitals are particularly likely to be isolated from communities. The isolation is more than physical. Since most hospitals do not have specific policies regarding immigrants and refugees, their staffing patterns, hiring practices, training programs and physical facilities often fail to reflect the multicultural diversity of their patients. Lacking appropriate training and resources such as interpreters, hospital personnel frequently perceive migrant patients as troublesome and unrewarding.

Public education is one way to promote the appropriate use of formal mental health services. @y submissions which discussed the problem Of underutilization of services urged that educational materials be developed, translated and disseminated.

effective educational materials share a number of common features:

C use of pictures as much as, or more than, words, "like UNICEF programs on health for Third World countries".

(Submission: Centre Portugais de Reference et Promotion Sociale)

C use of ethnic media, particularly television and radio, rather than general community media. For example, a series of programs on mental health was recently produced in Japanese for Vancouver's Multicultural Channel.

(Submission: Japanese Community Volunteers' Association)

C use of immigrant service agencies as much as, or more than, general community agencies for disseminating printed materials.

Outreach materials should address at least three topics: what mental illness is and how to recognize it; what mental health care is Eke and why it is offered; and how to gain access to local mental health services. As discussed in more detail in Chapter Six, multilingual information about the psychological effects of migration, settlement, and acculturation has also proven helpful.

In some large urban areas, mental health education personally delivered to community groups by multicultural or ethno-specific health workers has been effective.

The more personalized the delivery of mental health outreach services, the greater their effect in increasing the use of mental health remedial services. As the Southeast Asian Service Centre (Toronto) notes, for immigrants and refugees in stressful situations to use appropriate mental health services, "a labour intensive, one-to-one outreach is often required.'

Cultural and language barriers may be responsible for incorrect assessments and for treatment difficulties.

Ethno-cultural groups and service providers agree that lack of common language is the barrier which interferes most with assessment as well as treatment. As a submission from M.O.S.A.I.C. in Vancouver notes, "We speak to our emotional needs and describe traumatic experiences in our first language. " Yet many treatment agencies are staffed entirely by people who cannot speak to newcomers in their first language.

Assessment, during which a therapist makes a judgement about a client and arrives at a conclusion regarding his or her psychiatric status, is subject to potential bias of many types. One study found that when therapists routinely interviewed patients, they tended to assign diagnoses of depression more often to whites and of schizophrenia to blacks. When they used a standardized interview form, differences between blacks and whites disappeared. The

implication of these findings is that, in day-to-day clinical practice, therapists may fail to collect all the information relevant to making a diagnosis. Cultural stereotyping may lead to inappropriate short-cuts in data-gathering. Southeast Asians typically will not volunteer that they are feeling depressed, a phenomenon which has led many clinicians to speculate that when Asians become psychiatrically disturbed, their illness experience is different from Caucasians. However, research has demonstrated that despite their reluctance to volunteer their depressed feelings to physicians, Asians have an extensive vocabulary for depression and, if asked, will report these feelings.

Racial stereotypes may bias assessment.

Lacking adequate understanding of a patient's background, a practitioner may fail to understand the significance of certain symptoms. For example, a Canadian doctor may diagnose schizophrenia in a person from a developing country, failing to recognize that the psychotic behaviour results from malnutrition and related Vitamin B deficiency. (Submission: Canadian-African Newcomer Aid Centre of Toronto)

Assessment is a two-way process: while therapists diagnose their patients, the clients are deciding whether their potential therapist is likely to help them. Premature termination of treatment is a major problem. Many ethnic patients do not continue treatment after their first mental care contact and as many as half drop out before five contacts. The most common reason for dropping out of treatment is because of negative feelings towards therapists. Clients often suspect that their therapist is racist. Unfortunately, clients rarely discuss these feelings with the therapist or with anyone else.

Cultural differences also affect clients' responses to and the outcome of the two most commonly used forms of treatment: drug therapy and psychotherapy.

In the view of some ethnic groups, Canadian physicians are too ready to use medication in inappropriate situations. It has been alleged, for example, that Italian Canadian girls have been "treated with neuroleptics (drugs used to suppress psychotic behaviour) when in fact they were going through a traditional mourning process' (Submission: COSTI-IIAS). Research suggests that both Asian and Hispanic patients respond to both neuroleptic and antidepressant medications at lower doses than non-Hispanic whites. In addition, they develop disturbing side effects at lower levels of the drugs. Clinicians who are not aware of such findings and prescribe medication according to dosage schedules, which they have learned are effective with majority culture Caucasians, risk inducing side effects and setting in motion disaffection and premature termination.

While there are many specialized forms of psychotherapy, they are united by the common feature that a patient and therapist come together to explore the patient's problems through talk. The work of psychotherapy may be impeded by clashes in values, differences in expressive a nd problem-solving styles and incongruence of expectations. Western psychotherapists expect patients to express themselves freely, to disclose intimate thoughts and feelings and to understand that examining emotional conflicts in depth helps resolve psychological problems. However, some Asian cultures prohibit public expression of feelings through words, often relying on subtleties of vocal inflection and gesture as well as a reliance on metaphor whose significance may escape someone unfamiliar with the culture. Many Asians believe that mental disorder is caused by morbid thinking as well as by organic factors. If the practice of psychotherapy forces them to focus on painful (morbid) thoughts and de-emphasizes somatic interventions, many Asian Canadian clients may find psychotherapy inconsistent with their beliefs.

While North American therapists tend to treat their clients in an egalitarian manner, Asians expect a therapist to be an authority who will provide them with direct advice and information. Canadian therapists, as members of a culture which values independence, tend to make emancipation from the family in which they grew up one of the goals of successful therapy. This goal, however, may clash with the values of an Asian or African patient, whose culture stresses that the individual is important only as a member of his or her family.

Whereas many Canadians accept individual treatment as a matter of course, this may be unacceptable in cultures where families continue to play a central role in the lives of individuals.

The final phase of mental health care - rehabilitation and reintegration into society - poses a particularly difficult problem for both practitioners and patients. With what society is an immigrant to be reintegrated? As the Hong Fook Mental Health Association points out, "If our chronic clients are placed in a day program of a mainstream agency, they will become anxious and disoriented as a result of language and cultural barriers.'On the other hand, the ethno-cultural community from which the individual comes, is highly unlikely to have any out-patient programs or group homes. In all of Toronto, there are only six ethno-specific mental health services with an average of two full-time staff at each, even though over half the city's population reported non-British ethnic origins in 1981 (Submission: Community Resources Consultants of Toronto). In regions with few immigrants, reintegration in a familiar cultural environment may prove impossible.

The efficacy of mental health services depends on good communication, accurate diagnosis, effective treatment and appropriate follow-up (Lawson et al., 1982). Communication with family, when family are available, is always essential. While Canadian mental health professionals are becoming increasingly skilful at involving families in therapy, the idea of communicating with a community in which an individual may be ultimately imbedded, is a foreign one. The admonition to do so may create difficult professional and ethical issues.

This submission illustrates the centrality of community in the lives of some ethnic groups in Canada. The Eritrean community presented its brief with a sense of outrage that one of its members had been admitted to a hospital without prior consultation with the community. In this spirit, the community believed that failed treatment was to blame for the patient's worsened condition. It is possible, however, that the man's behaviour after discharge was part of the process of his illness rather than the result of bad treatment. No one communicated this possibility to the community. If they had, it is questionable whether the Eritreans would be willing to accept this idea.

This case illustrates another problem - the conflict in values between Canadian and Eritrean society. During the hearings, the Task Force indicated that, under Canadian guidelines, if the patient had requested that the community not be informed of his hospitalization, treatment staff, following right to-privacy guidelines, would have complied with his request. The Eritrean response was that the right of the community to know overrides the right of the individual.

There is no clear-cut solution to this quandary. However, the incident illustrates how alienation and disaffection with the mental health care system can occur if we fail to address the needs of the social network as well as those of the individual patient.

Concerns regarding the efficacy of mental health services by immigrants and the failure of mental health services to help immigrants are being addressed by individuals, groups and institutions across the country. To a large extent, the impetus for change is coming from the " roots' level front-line service providers and ethnocultural community leaders who see the barriers to utilization and effectiveness at close range.

Since most policies governing the mandate, organizational structure, and funding of mental health services are determined at the provincial government level, service providers and community leaders are limited in the changes they can directly implement. Considerable effort, therefore, goes into advocacy.

Some of the innovative policies and programs reported to the Task Force are the results of such advocacy work. Others exemplify steps that can be taken within existing financial and organizational limits to improve mental health care for immigrants.

Language is the most ubiquitous barrier to effective mental health service. At present, untrained, underpaid and unofficial translators are used on an ad hoc basis in situations ranging from psychiatric emergencies to extended counselling sessions.

Interpreters are difficult to find. Poor-quality interpretation distresses clients and causes problems in treatment.

Using an interpreter in assessment and counselling sessions takes twice as long, and important nuances are frequently missed. Because most social, health and community agencies have suffered staff cutback in recent years, and remaining staff are heavily overburdened, the extra time it takes to work through an interpreter is a serious consideration.

(Submission: British Columbia Association of Social Workers)

Hiring ethnic mental health professionals to work in service agencies seems a way to overcome linguistic and cultural barriers. For several reasons, some of which are discussed in Chapter Eight, this solution is beset with problems. Since it is impossible to imagine that any mental health facility could ever have at least one worker for every ethnic group it serves, mental health facilities will always have to offer help through interpreters, at least to small linguistic communities.

Effort must be directed towards improving translation services.

Funding is the main obstacle to training and using qualified interpreters.

B. Cultural Awareness

Cultures need to be interpreted as well as languages. Mental health service providers often call on staff from immigrant service agencies for language translation and interpretation. After the first contact, others may follow, during which language concerns expand to the acquisition of other information about clients and their backgrounds. As cultural awareness builds in mental health service providers, their services improve.

Reciprocal staff training provides a logical linkage between provincial mental health services and immigrant service agencies (see Chapter Seven).

In the Edmonton Region, the decision was made to develop a Reciprocal Training Program aimed primarily at assisting Settlement Counsellors to recognize mental illness and Mental Health therapist to understand the culture and adjustment process experienced by the predominant immigrant and refugee groups.

(Submission: Alberta Mental Health Services)

When Alberta's Reciprocal Training Program was evaluated, it was expanded to include an informal system of reciprocal case consultation and co-therapy as well as reciprocal education.

Such arrangements often yield three immediate results: mental health practitioners develop an increased awareness of cultural issues affecting service delivery; immigrant service providers gain an understanding of mental health and illness; and immigrant patients probably receive more effective mental health care than they would otherwise.

The mutual benefits and cost effectiveness of reciprocal training, case consultation and co-therapy are lauded by all concerned. Despite the benefits of learning from immigrant service providers, surprisingly few mental health services offer any systematic opportunity for improving staff sensitivity to cultural issues. Instead, a few individuals with a special interest in migrants become members of interagency committees. These committees share information and promote cultural awareness through workshops, newsletters, and advocacy.

The agencies that employ committee members vary greatly in the support they offer committees and the extent to which they are influenced by them. In some instances, mental health services actually spearhead the development of networks. In other cases, however, staff are not permitted to attend committee meetings during work hours.

Cultural awareness should include a knowledge of healing resources within ethnic communities. However, very little is known about indigenous and folk healers. Isolated case reports suggest that people rum for help with emotional problems to such healers, who may have no "official" credentials, but instead, practise by virtue of community sanction. Some commentators suggest that these practitioners represent an untapped mental health resource while others warn against the possibilities of charlatanism. Information for judging indigenous healers is lacking. There is a need to know how and under what circumstances people turn to indigenous healers. Do they use them as substitutes for, or as an adjunct to the health care system? How widespread are these practices in different ethnic communities and what benefits, if any, do they provide? An inquiry into thew important questions will benefit from the background of research emanating from developing countries as well as from native Indian communities in North America.

C. Program Development

Innovations in mental health care programming for immigrants are being introduced in c)existing mental health facilities, in immigrant service agencies, and through outpatient services in community settings.

The barriers to using mental hospitals, psychiatric wards in general hospitals and mental health clinics are formidable, yet resources are concentrated within these facilities, particularly those which can meet the needs of severely disturbed individuals.

Whether multicultural or ethno-specific, immigrant service agencies have fewer problems with access than designated mental health facilities.

Practitioners must make a special effort, however, to secure collegial and professional support.

As O.A.S.I.S. Immigrant Services Centre notes, when a mental health practitioner is stationed at an immigrant service agency, advantages accrue to both counsellor and client:

C the implications of cultural background factors and cultural adjustment processes are weighed and discussed by the mental health practitioner with immigrant service staff;

C accurate information on resources helpful to immigrants (family reunification possibilities, language training programs, employment and life-skills training) is readily available from other staff;

C when non-mental health community institutions are involved (Workers' Compensation Board, the legal system, unemployment insurance), the mental health practitioner has the mandate to introduce them to the client, and the client to them; and

C the roles of various mental health resources such as alcohol treatment programs, family counselling services, and self-help groups are coordinated and overseen by the practitioner.

In other words, mental health service providers located in immigrant service agencies can act as case managers, avoiding much confusion and stress for clients and their families while providing and Facilitating services that are tailored to the clients' needs (Submission: O.A.S.I.S.).

These services are usually linked to particular ethnocultural groups. Ethno-specific mental health services, as several submissions indicated, combine the advantages of general community mental health facilities with the advantages of immigrant service agencies.

One of the main disadvantages of ethno-specific service is cost. Ethno-specific mental health programs are found only in the largest urban areas, and then only in the largest cultural communities. For less populated regions and smaller ethnic groups, liaison services, where immigrant service agencies serve as the bridge to general community mental health facilities, seem the practical solution to the issues of both underutilization and service inefficacy.

Liaison and bridging mechanisms have proven quite successful in getting immigrants with mental illness into care, in explaining mental health services to patients and their families, and in Draining cultural background and context to mental health practitioners. Reintegrating a person with mental disorder into the community, however, calls for more than liaison services.

Ethno-specific programs for the rehabilitation and reintegration of immigrant patients are necessary and warranted on two grounds. Individuals recovering from mental illness can be expected to integrate best in a familiar cultural environment. 3 L Depending on an immigrant's level of acculturation, that environment will not be found in group homes or halfway programs serving Canadian-born persons.

Depending on the cultural conceptions of mental disorder in an immigrant's own community, his or her needs for housing, social support and employment will not be met. For the unacculturated individual from a traditional community, ethno-specific services are a requisite for successful follow-up treatment.

Funding problems beset efforts to increase immigrant use of mental health services as well as improve the effectiveness of these programs. The same problems also Emit attempts to improve the situation for native-born populations and mental health services. For immigrants, however, the problems are of an entirely different magnitude.

Lack of funding for multilingual, culturally attuned outreach programs results in crises which otherwise could be prevented. Increased demand for emergency services and acute mental health care is also required. Prolonged human suffering often results from delays in early effective management.

Lack of funding for interpreters and multicultural or ethno-specific services compounds the anguish of immigrants in need of help and may result in a premature end to service. It also produces what is known as the "boomerang effect " - immigrant service agencies refer clients to mental health services, only to have them referred back again. Time, money, and energy are wasted in the process.

As the sine qua non of remedial mental health services, funding requests become the subject of most lobbying efforts:

It is essential that the formal mental health care system become more responsive to the needs of immigrants and refugees. Of the many ways in which mental health service dollars could be used to increase and improve the formal mental health care provided immigrants and refugees, the Task Force assigns priority to four.

Since immigrants and refugees now resist using mental health services, outreach is a prerequisite to service delivery. The Task Force recommends that Health and Welfare develop, in collaboration with immigrant service agencies and ethnocultural organizations, multilingual educational materials on the psychological consequences of migration and the resources for mental health care. Health and Welfare should provide these materials to provincial ministries of health and immigrant service agencies for dissemination through front-line service providers and ethnic media. There is an urgent need as well for Health and Welfare to review and update its existing health and mental health-related materials to ensure that they are culturally sensitive and relevant.

Trained cultural and linguistic interpreters are imperative for the delivery of effective mental health services. Interpretation will also aid in crossing the barriers that prevent access to mental health services by immigrants and refugees. The Task Force recommends that Health and Welfare, in collaboration with provincial ministries of health and immigrant service agencies, develop a curriculum for training interpreter used by mental health services. Immigrant service agencies and provincial ministries of health should be provided with this curriculum for use in classes supported by Health and Welfare.

Making services more accessible requires more creative initiatives and more flexibility in cxperimenting with models of service delivery. We will need to provide more opportunities for mental health care workers to go to their potential clients rather than to wait for clients to appear in their offices. The Task Force recommends that Health and Welfare encourage provincial mental health services to employ mental health practitioners at major immigrant service agencies. Every effort should be made to place professionals who can communicate with a sizeable proportion of clients in their own language.

After treatment, successful rehabilitation and reintegration into society depend on specific programs to serve the needs of migrants. It is recommended that Health and Welfare encourage provincial mental health services to give special consideration to the funding of ethno-specific rehabilitation and reintegration facilities.

Other recommendations, which address the need for new program initiatives and training to ensure that workers are culturally sensitive, are presented in Chapter Seven and in the Conclusion to this report.

Parenting classes, peer counselling groups, and visits by a friendly public health nurse help newcomers resolve problem just as they help native-born Canadians. In addition to their major functions, the agencies which provide these services help people cope with stress and, thereby, often help prevent emotional problems from evolving into psychiatric disorders. Although it is not often recognized, community service agencies, some ethno-specific organizations and primary health care providers make up a de facto system of mental health care, operating outside the formal mental health system.

Agencies and organizations which play or could play a role in mental health care can be divided into two categories depending on the populations they serve. General community service agencies and organizations in theory serve "everybody" but in fact are designed for and by members of the majority group cultures. Immigrant service agencies and ethnic organizations exist to meet various needs of foreign- born persons and members of ethnic minority groups.

As noted in Chapter Five, immigrants and refugees prefer to seek help for emotional problems from service agencies and organizations outside the formal mental health system. However, the help they receive from general community services is limited because of cultural barriers, and the help from immigrant services is limited by restrictions placed on funding and mandate.

Newcomers are more likely to use an organization which is physically accessible and an integral part of their community life, in preference to one whose services appear specific to mental health.

A side benefit is that, the more immigrants and refugees use general community services, the more they become integrated into the larger society.

Submissions to the Task Force suggested that, among organizations serving the general community, family services, public health departments and neighbourhood houses play particularly important roles in migrant mental health. The role of school boards and other agencies focussing specifically on children is discussed in Chapter Nine.

Family services associations provide counselling to families and individuals. The Family Services Association of Metropolitan Toronto, which serves more than 10,000 families and individuals per year, is involved in the resettlement of refugees as well as ongoing counselling. Caseload problems include parent/child and spousal conflicts which have unique cultural dimensions.

Family tensions often arise when immigrant children adopt the ways of the majority culture faster than their parents. When they begin dressing or acting like their peers, children may violate their parents' cultural norms and their behaviour may seem shameful or disrespectful. When immigrant women adopt the Canadian ideology of sexual equality, this can be stressful for husbands and contribute to marital tension. Family service organizations can accommodate these needs by ensuring that their staff represent the major cultural groups, by offering training in cultural awareness and by providing bridging services with ethno-specific organizations.

Some family services associations offer appropriate mental health programs for immigrants as well as the general community, but access to them is limited by financial constraints. Medical care plans do not cover fees for these mental health services.

Several public health departments have incorporated the multicultural needs of the community into their health promotion programs. Until recently, when funding cutbacks jeopardized their programs, the Vancouver Health Department was providing prevention services to immigrant and refugee elementary and secondary school pupils. These programs, carried out by psychiatrists, nurses and interpreters, many of whom were immigrants themselves, offered two levels of service. Primary prevention included social support groups for parents and teenagers, cross-cultural sensitization sessions with family physicians and community health nurses, and the provision of health education materials. Secondary prevention included direct and indirect case consultation, crisis intervention, short-term counselling, and interagency coordination and follow-up. The cases involved family violence, academic underachievement, and youth anxieties emanating from being caught between peer pressure and traditional family or religious role expectations. In its submission to the Task Force, the Vancouver Health Department stressed the need for a coordinated effort to solve problems; case management must be shared by a variety of persons such as school counsellors, mental health staff and family physicians. The department also stressed the advantages of coordinated problem-solving.

The City of Toronto Health Department attempts to meet the multicultural needs of Metropolitan Toronto by fostering community development, supporting a multicultural mental health workers' network, and disseminating culturally sensitive health related materials. The department also addresses barriers to access with an equal opportunity hiring policy, and advocacy with planning and funding bodies.

In cooperation with ethnic organizations, the Board of Health in Edmonton operates special programs for immigrants such as prenatal classes, discussion groups on stress, nutrition and family planning, and summer camps for children.

Community-based neighbourhood houses also provide services which support mental health. The Association of Neighbourhood Houses of Greater Vancouver acts as a preventive and supportive resource to immigrants by offering preschool and after-school care, ethnic nights, citizenship classes and special interest groups. A neighbourhood house may assume the role of broker between immigrants and non-immigrants in the community. Sensitizing the general community to cultural differences helps create an environment of acceptance for immigrants.

The activities of multicultural and ethno-specific immigrant services have important mental health ramifications. Some groups provide individual and family counselling to ethnic minorities. Others support ethnic community development. Some organizations serve as a liaison to general community services. And others serve highly specialized roles, such as employment preparation and skills training.

Multicultural ethno-specific agencies employ bilingual and bicultural workers, many of whom have personal experience as immigrants or refugees. Community outreach and public awareness programs are often used to catalyze community development, to promote advocacy, and to educate the general public. Self-help and community organizations created and run by ethnic communities also play a role in mental health.

One example of a multicultural immigrant service agency is the Catholic Immigration Bureau which provides social services to immigrants and refugees within the Archdiocese of Toronto. By using innovative programming with a knowledge of the culture, this bureau dealt effectively with what seemed like an epidemic of marital problems in the Portuguese community. Success was due to the cooperation of professional staff, religious and other community leaders, and to the sensitivity with which the program built upon existing cultural patterns.

In the same culturally sensitive manner, the Catholic Immigration Bureau offers settlement services which a-re integrated with personal, vocational and family assessment and counselling.

Even if they do not have formal social or counselling services, churches to which immigrants and refugees belonged prior to migration are perceived to be sources of aid and comfort in Canada. This makes them a potentially important source of referral for mental health care.

The Strathcona United Chinese Community Enrichment Services Society (S.U.C.C.E.S.S.) in Vancouver is an example of an ethno-specific agency which provides social services for immigrants. This Chinese community social service agency is one of the largest of its kind in Canada. S.U.C.C.E.S.S. offers family fife education, marriage enrichment, and parenting groups. O.A.S.I.S., the Orientation Adjustment Services for Immigrant Societies, also in Vancouver, provides language translation and family counselling as well as formal mental health services. In Toronto, the COSTI-IIAS Family Counselling Centre assists Italian Canadians in resolving spousal and intergenerational conflicts. Newcomers from Africa living in Toronto can obtain help from trained ethnic counsellors at the Canadian-African Newcomer Aid Centre of Toronto (C.A.N.A.C.T.); those from Portugal living in Montreal, from the Centre Portugais dc Reference et Promotion Sociale.

The Southeast Asian Services Centre, a multi-services agency in Toronto, operates a public housing project for Vietnamese refugees. Through non-threatening activities such as social clubs for seniors, the centre also attempts to create a familiar environment for migrants. The South East Asian Refugee Community Organization of Manitoba (S.E.A.R.C.O.M.) develops familiar cultural activities for Southeast Asian youth.

The Jamaican Canadian Association, which introduces community support through its "Pal Program," organizes volunteers to act as big brothers or sisters to young people in need of a friend and role model.

Some ethno-specific agencies in larger urban centres have a specific focus on mental health. Community Resources Consultants of Toronto reports five ethno-specific mental health services in Metropolitan Toronto which serve immigrants and refugees. They include: Hong Fook, an organization which offers supportive services in addition to providing inter-agency liaison; Breakthrough, a weekly support group for Italian women; Jerry Turk Fellowship Home, a supportive housing resource with a Jewish orientation; Portuguese Community Mental Health Project, an assessment and counselling service; and Kensington Clinic, an addictions Clinic for Portuguese people.

Ethnic communities develop at different rates and have varying needs and specific concerns at different times. Ethno-specific agencies help fulfil immediate needs, particularly for those clients who do not speak one of Canada's two official languages. Ethno-specific agencies may not, however, constitute a viable long-term solution for all groups. Some ethnic groups may not wish to support such services. Exclusive reliance on ethno-specific services also reinforces the marginalization of clients and may isolate ethnic paraprofessionals in dead-end career paths.

Some organizations enhance the mental health of immigrants and refugees indirectly by coordinating the services of other agencies. Instead of providing direct service, these groups are dedicated to forging links between general community services and immigrant or ethnic services.

The Immigrant Access Service of Manitoba, with a multicultural, multilingual song, provides an important model for long-term planning. The Hong Fook Mental Health Association of Toronto provides another example.

Like some other liaison organizations, Hong Fook serves an ethno-specific clientele. This is an important feature because it recognizes and promotes the importance of cultural values in providing services. "It is important that solutions should be sought within the particular cultural context, that is, the values in terms of which people organize their lives (Agard, 1987).

Other liaison organizations include the Portuguese Interagency Network, Metropolitan Toronto

Multicultural Mental Health Group, Multicultural Health Coalition, and Alberta Association of Immigrant Serving Agencies.

The well-being of immigrants and refugees is, or should be, the business of all levels of government and all agencies - the formal mental health care system, general community services and immigrant service agencies. Many of these entities demonstrate the dedication and creativity of Canadians committed to the business of resettlement. At the risk of discouraging these efforts, it must be recognized that they offer a fragmented service. Provincial services are organized in ways which make sense for a stable society but not for newcomers, whose needs tend to be interdependent and overlapping. Language difficulties are inextricably tied to job training and employment; concerns about housing, which merge with needs for social benefits, may have an important impact on health.

Newcomers' needs cannot be neatly divided to conform to the speciality of a particular agency. Staff of government ministries and government supported agencies tend to become specialized in dealing with a particular type of problem. Immigrants and refugees frequently find themselves on an exhausting and demoralizing trail of referrals from one office to another in search of more specialized help, for reasons which they cannot understand and which they may interpret as rejection.

The inefficiency and frustration which result from fragmentation has led some to call for governments to change the way they are organized to meet changing needs.

The benefits of an integrated system of care, with optimal communication and cooperation between service agencies, are recognized both by communities and by care-giving organizations. One of the submissions to the Task Force painted a realistic picture of how better integration of service would help overcome the barriers to mental health care experienced by so many new settlers.

This excerpt is important in that it indicates that the mental health care system is a link but not necessarily the final link in a chain of care. There is a role for representatives of ethno-specific organizations to act not only as sources of referral for mental health care, but also as consultants and interpreters during treatment, and as helping agents in planning after-care and rehabilitation following an episode off illness.

To some extent, fragmentation results from competitiveness, both personal and at the level of agencies and bureaucracies. Instead of cooperating, agencies find themselves competing for scarce resources, whether for personnel with special attributes and believes, skills or for funding. The Task Force believes, however, that the source for many of the difficulties is structural; the way in which services are organized is dictated too much by political and professional fiefdoms rather than by patterns of need.

Remedies for this situation must include incentives for service agencies to become more responsive to the needs of immigrants and refugees. The Task Force recommends that Health and Welfare and Secretary of State encourage all funders of social and health services to require that organizations applying for funds provide evidence of efforts to make their services accessible to ethnic minorities and to provide evaluations of their effectiveness. Funding criteria should include linkages between general community services, immigrant service agencies and ethnic organizations, and interagency committees to develop, monitor, and refine means of liaison.

Mental health must become a recognized part of the mission of agencies which deal with immigrants and refugees. Health and Welfare should encourage and support the immigrant volunteer training programs with peer counselling components at immigrant service agencies. Incentives must be provided to stimulate mental health services to integrate their expertise with community, immigrant serving, and ethno-specific agencies. The Task Force recommends that Health and Welfare identify immigrants and refugees as well as multicultural concerns among its priority areas for Health Promotion contributions, research and National Welfare grants, and other funded activities. Health Promotion Contributions should be available to promising and deserving organizations whether they are nationally or provincially based.

To reduce fragmentation of services and enhance integration, a new group should coordinate and monitor programs as well as enhance cooperation between the many agencies and departments serving immigrants in Canada. The Task Force recommends that Health and Welfare establish a

national advisory body to coordinate and monitor social, health and mental health services to ethnic minorities, with participation from professional associations, service administration, and immigrant service agencies. Health and Welfare should also encourage the creation of a similar advisory body in each province.

When appointing persons to federal or provincial advisory councils, boards, and commissions on health, mental health and social services, Health and Welfare and its provincial counterparts should consider the candidate's knowledge, experience, and sensitivity regarding immigrant and ethnic minority issues.

Next

Background - Executive Summary - Chapter 1 - Chapter 2-6 - Chapter 7-9 - Chapter 10-11 - Chapter 12 Conclusion & Appendices

Virtual Library		Updated February 09, 2004