Hung-Tat Lo

Rose Lee

1992

As population movement increases, ethnocultural diversity is a fact of life in many parts of the world. Many members of ethnocultural minorities are immigrants and refugees and their offspring. Mental health issues concerning these groups have been documented and studied (Salvendy, 1983), and the importance of providing them with linguistically and culturally appropriate services has generally been accepted (Draguns, 1981). However, the means by which this can be achieved is still very much open to question.

After The Door Has Been Opened is a recently released report (Canadian Task Force, 1988) that documents the current status of such services for ethnocultural minorities in this country. Most of these services are community-based, as shown in a review by one the authors of such programs in England, Australia and North America (Lo, 1990a). Generally, however, descriptions of such programs have not appeared in the literature, and a systematic study of them is quite difficult. In this paper, we would like to present a detailed description of a particular service delivery model in practice. It has evolved in Metropolitan Toronto over the past decade to address the mental health needs of the Chinese and Southeast Asian populations.

Before describing the Hong Fook model, it is useful to examine the general problems that arise in providing services to these immigrants. Service delivery might be defined as the matching of manifest problems in the population with the available resources in the system. We shall briefly review these two aspects as they relate to our particular populations.

According to the 1986 Census, approximately 140,000 ethnic Chinese, Vietnamese, Cambodians and Laotians lived in the Metropolitan Toronto area at that time (Canada, 1986). They are primarily immigrants and refugees who have settled in Canada over the past few decades. As in the United States, they have been found to under-utilize mental health services (Cheung & DuBois,1982) despite evidence that they do experience a significant level of emotional distress (Nguyen, 1982). The stresses of immigration with its attendant losses, along with the challenges of adaptation to a new society, often lead to psychiatric morbidity. At times, this is further compounded by the effect of socioeconomic handicaps and even racism.

However, a lack of understanding or a fear of mental health issues and the service delivery system have typically produced among our target population a protracted response in seeking help. Clients often present only at a late and severe stage of illness, and after there has been significant family involvement (Lin et al, 1978). When the clients and their families do encounter mental health professionals, linguistic and cultural barriers often interfere with the diagnosis and treatment that is provided, a fact that may eventually lead to poor compliance and treatment failures (Sue, 1975). Bitterness and disappointment are felt on both sides, which inhibit the parties from making any further attempt to renew such therapeutic contacts.

The resources that are available to Asians in Toronto vary within the different ethnocultural communities. By the late 1970s, the Chinese community already had many physicians, including a number of psychiatrists. There was also a growing contingent of social workers, nurses and a few psychologists:-A significant number of them spoke Chinese, which was unlike the situation in some other North American cities where most second-generation Chinese professionals had already lost their native language.

However, most of the Chinese-speaking professionals in Metropolitan Toronto worked in different institutions where there was no specific mandate to serve t)1e Chinese immigrants. While on occasion they might be consulted by their colleagues or might interpret for Chinese clients, their individual workload or even at times their own vocational aspirations (in not choosing to work for their own ethnic group for various reasons) had rendered this response inadequate in meeting the needs of the population. Without an ethnospecific program or a specific mandate in an institution, the mere presence of bilingual staff had not led to significant improvement in the situation (Lo, 1990c). On the other hand, the size of the Chinese caseload in most institutions, although increasing, did not justify the establishment of such programs. For the same reason, establishing a comprehensive service network for this single population, or for any other, was out of the question.

The professional resources for the Vietnamese, Cambodian and Laotian communities were even more limited. In many instances, the Chinese professionals were asked to provide assistance for them even though they did not share a common language or culture.

It was under these circumstances that a group of professionals in Toronto who were Chinese got together in 1978 to discuss the issues of mental health service delivery to the Chinese community. The members of the group met regularly and formed the Hong Fook Mental Health Association, "Hong Fook'; meaning "health and happiness" in Chinese. Further momentum gathered in 1979 when "boat people" began to arrive in the city. The group responded to this situation and extended their target population to include Southeast Asians. With the assistance of the Social and Community Psychiatry Section of the Clarke Institute of Psychiatry, the group obtained funding from the Ontario Ministry of Health to set up a community mental health program. In September 1982, the Hong Fook Mental Health Service began its operation (Mears, 1984). Other sources from both government and voluntary sectors such as the Secretary of State, Canada Employment and Immigration Commission, the Ontario Ministry of Citizenship and the United Way have since provided project funding to support Hong Fook's other initiatives to promote mental health in the target population.

The board of directors of the Hong Fook Mental Health Association, which is an incorporated non-profit organization, formulates policies and directions to guide service delivery and program development. As of 1990, there are four standing committees, and over 100 members provide the Association with significant volunteer manpower and expertise. The day-to-day operations of the Association are carried out by bilingual and bicultural staff that consists of an executive director, an administrative assistant, a senior mental health worker, three other mental health workers and two community education workers, one of whom works half-time. A bilingual and bicultural sessional psychiatrist provides regular psychiatric consultations to the staff as well. Other project staff includes one worker for a mutual support group for young Vietnamese adults, and one worker for a project to advocate primary prevention and mental health promotion activities for newcomers to Metro Toronto. Since 1990, the Association has served over 1,300 clients, and the current active caseload is around 150. These figures do not include the indirect services that are offered, where individual charts are not maintained for the clients.

There has been significant growth in our target populations, with the Chinese now numbering over 200,000, the Vietnamese over 30,000, and the Cambodians over 5,000. Our services must continue to evolve to meet the emerging needs of these populations (Lo, 1990b).

The Hong Fook model is designed to offer services to both individuals and groups, and to the community at large. It also provides professional development activities for mainstream professionals and extensive interagency linkages, collabration and advocacy.

The casework services to individuals are best described according to the sources of referrals.

When a Hong Fook worker is contacted by the staff of a mental hearth agency such as the psychiatric unit of a general hospital that has admitted a Chinese or Southeast Asian patient, he/she goes into the hospital to assist in the assessment of the client by providing linguistic and cultural interpretation. The worker can help collect the relevant psychosocial information from the patient and the family and arrange for other consultants if necessary. This leads to a comprehensive assessment of the client and his/her circumstances, which in turn produces a culturally appropriate treatment plan. During the time that this process is under way, the worker also helps the client and family understand their situation, so that their fear is relieved and they receive sufficient support to cooperate fully with the treatment plan.

This kind of supportive counselling continues throughout every stage of the hospita1ization and helps build up rapport between the worker and client, an element that is essential to the follow-up work in the community. A vital role is played by the worker during hospital discharge planning, where his/her knowledge of and connections with community resources combine to help facilitate appropriate referrals and adequate disposition for the client. Following discharge from the hospital, the client may also, if necessary, be escorted to follow-up appointments. No effort is spared to ensure the proper execution of the discharge plan. This facilitatory role continues as the client proceeds to different aftercare agencies such as a boarding home or a workshop.

When the mental health professiona1 who follows up the client does not speak the appropriate language, the worker not only provides interpretation and support as described above, but may also become a co-therapist. The worker would then participate regularly in all therapy sessions and perform certain therapeutic functions inside or outside of the sessions, depending on the treatment plan that is worked out with the primary therapist. This might involve supportive counselling to encourage the client to participate more actively in therapy, or coaching him/her in certain life skills. It might also include working with the client's family. The role of the co-therapist is particularly important in the Southeast Asian populations, where there are very few accredited professionals.

For clients who are chronically disabled and who have multiple needs that require service from a number of different agencies, more comprehensive case management is often needed, and the Hong Fook worker may be the person best suited to fulfill this function. The worker may also be called upon to provide additional in-depth counselling for such clients. It is evident that through all these activities, the worker plays an advocacy role in order to ensure that the needs of both the clients and their family are met.

The Hong Fook worker may be asked to provide information of a general nature regarding services or mental health problems for other service providers who have no specific mental health mandate (e.g., from immigration services, the police, community centres, etc.). The worker may also be called upon to provide a preliminary mental health assessment of a specific client who is deemed to have a mental health problem, and to recommend appropriate disposition. The client may need to be linked to appropriate services such as psychiatric assessment or hospitalization, and the Hong Fook worker is able to provide a referral because of ongoing involvement with such resources. When the onset of treatment is delayed for various reasons (such as when non-certifiable clients refuse treatment), the Association remains involved with the case, providing support to the family and waiting for an opportune moment to intervene more actively. At times, the situation may become acute and crisis intervention is provided.

Over the years, consumers, families and friends have increasingly requested Hong Fook services directly. Much effort has been spent educating such ethnic community members about mental health issues and coaching them to make effective use of mental health resources. Hong Fook also advocates on their behalf to gain access to services. In some acute situations, active intervention is required before the client can be engaged in a treatment service.

As Hong Fook evolves, it has become evident that certain group programs are needed to complement the casework that is done. Psycho-educational groups for families have been offered, and there are now some support groups for isolated clients.

An innovative group program has evolved out of the English as a Second Language (ESL) class that is operated jointly with the Toronto School Board. Ten classes are offered each week for psychiatrically impaired students who cannot keep up with regular ESL classes. An enthusiastic teacher has planned various activities that are supplemental to the classes, which include outings, Chinese calisthenic exercises and other recreational pursuits. Such events have become the core of a social recreational group program that is being developed to meet the need for support and for structured activities among many of the Hong Fook clients.

In 1991, a consumer project was launched employing ten consumer workers who, among other duties, run support groups for other consumers in all three languages of the target populations. There is also a mutual support group for young Vietnamese adults, which is a primary prevention project sponsored jointly with the Vietnamese Association. The education worker also conducts group activities for a visa students association, and runs a support group for single mothers.

Hong Fook's community education workers develop and distribute written and audiovisual materials such as educational pamphlets and videotapes on the subject of mental health in the languages 01. the target populations. They make presentations to ESL classes, hold information displays and workshops, network and collaborate with groups and organizations such as the Canadian Mental Health Association (CMHA), Ontario Division, with whom they organize publicity campaigns and community events during the National Mental Health Week every year. Hong Fook also participates in interagency committees and community functions such as open houses and health fairs.

To enhance the responsiveness of the service delivery system, the Education Committee of the Association with the assistance of the staff organizes professional conferences, lectures, seminars and other educational activities. The staff are also responsible for making presentations to mainstream service providers to inform them of the Chinese and Southeast Asian cultural and health beliefs and practices and to sensitize them to cross-cultural issues that arise when working with the target population. In response to growing concern about cross-cultural training for mental health professionals, Hong Fook provides fieldwork placement for clinical clerks, psychiatric residents and social work students.

On the systems level, Hong Fook mobilizes resources to address unmet needs of the target population through interagency linkages, collaboration and advocacy. To improve the quality of care for Chinese and Southeast Asians, the Association has entered into formal agreements with hospitals such as the Queen Street Mental Health Centre, Toronto East General Hospital and the Clarke Institute of Psychiatry. Under these agreements, the Hong Fook staff are recognized as courtesy staff or consultants. They share the responsibilities for and provide input into the assessment, treatment, discharge planning and follow-up in the community for such clients.

The Association acts as an advocate in a number of other areas. In order to promote access to government-subsidized boarding homes, it has advocated to the Habitat Services, a program that oversees and allocates funds to boarding homes. Hong Fook has now been designated as an official referral source to their boarding homes. The Association has also collaborated with CMHA in a new project called the East Metro Multicultural Initiative that provides a program in housing and case management for Chinese living in the eastern part of Metro Toronto. Hong Fook has received funds from the Secretary of State to explore ongoing activities in the area of primary prevention among all the ethnocultural communities of Metro Toronto. As well, it participates in multicultural and advocacy bodies such as the Steering Committee of the Metro Toronto Multicultural Mental Health Group and Access Action Council Policy Review Group to bring about changes in the system, particularly on the planning and policy level. The Association is also part of the Chinese Interagency Network, and Hong Fook's members are widely represented in the different agencies of the ethnocultural communities.

From the outset, the goal was to develop a model that was cost-effective as well as linguistically and culturally responsive to its target population. There are certain characteristics that

distinguish the Hong Fook model as it has evolved over the past decade.

Hong Fook takes a free-standing, community-based approach to mental health service delivery. The program's location in the ethnocultural community provides ready access to its clientele. The program is accountable to the communities it serves through board representation and an active membership. As well, the bilingual and bicultural staff are active members of their respective communities. In addition, a strong relationship has been developed with the other community agencies. All these conditions are conducive to a sociocultural "fit" between the program and its target populations.

The membership of the Association includes mainstream professionals, who are interested in Hong Fook's work. They bring with them a broad perspective and contribute significantly to the work of committees. This creates a base for Hong Fook in the larger professional community as well. The fact that the association is free-standing means it is not officially affiliated to any institution to which it must answer. This improves the ability of the staff to streamline the organizational structure and process, thereby removing bureaucratic hurdles that often intimidate clients. Such flexibility also allows the staff a greater opportunity to be responsive and innovative.

The model promotes links with all the "players" in the field to effect optimal utilization of limited resources and to facilitate systemic changes. From the beginning, the model was based on a strong belief that the mainstream agencies have an essential role to play in services to the ethnocultural communities. They must become more responsive to their multicultural clientele, since it is unrealistic to expect that these communities can adequately meet all the mental health needs of their members by themselves. Such links are fostered by the very nature of Hong Fook's programs and by its special educational activities that are designed for mainstream professionals. On the systems level, Hong Fook links up with many services and organizations, including hospitals, community mental health programs, boards of education, multicultural organizations and advocacy bodies. Through joint projects and the sharing of information and resources, it attempts to bring about changes in mental health services at the program planning and policy levels by refocusing existing resources and developing new initiatives to meet the needs of the target population.

Comprehensiveness and continuity of care are key features of Hong Fook's service delivery. A comprehensive mental health system includes components of care in primary prevention, treatment and rehabilitation. Hong Fook directs its efforts to the whole spectrum of mental health care through a micro-macro approach. At the client's level, casework services are offered to ensure that the client receives continuous and appropriate care at every stage of his/her treatment and rehabilitation. Work is done with clients, their families and their primary professional caregivers as well as the agencies that serve them. On the community level, mental health education is provided for the purpose of primary prevention.

A major characteristic of the Hong Fook model is the maximum role flexibility adopted by our staff. Initially a consultation-Iiaison model was adopted whereby the staff would provide consultation to the mainstream professionals and members of the community in different situations, and liaise with the various services required by the client. In order to do this, the staff takes on, as required, the multiple roles of advocate, interpreter, teacher, counsellor or coordinator. The staff are highly mobile and provide the service where it is needed.

Over the years, a group of chronic and severely impaired clients has been identified who cannot be 1inked to any treatment or rehabilitation services because of linguistic and cultural barriers and because of the nature of their illness (Barwick, 1989). This circumstance led Hong Fook to expand its scope of service to provide care in the form of more in-depth counselling, crisis intervention, case management and group work.

Flexibility is also apparent in the type of staff that is hired. The current staff includes both accredited and non-accredited professionals of various disciplines (e.g., social workers, nurses, physicians and teachers). In the smaller ethnocultural communities, few accredited professionals arc available and yet there are individuals who are otherwise well-suited to serve their own community in the role of mental health workers. They usually have a good knowledge of the community, where they are well-accepted and often respected. They also have human services experience and community organization skills. With on-the-job training, adequate supervision and support and readily accessible psychiatric back-up they are valuable assets to our program (Lo, 1990c).

Education is stressed as an instrument that can empower and create change and it applies equally to the professional as well as to the ethnocultural communities. There is little emphasis on culture in the curriculum of most professional schools and a general lack of cultural awareness in the practice of many mental health professionals. The provision of education opportunities in cross-cultural health care, which wil1 enhance the competence and understanding of professionals, is thus very important. On the other hand, education for the ethnocultural community members aims at reducing the stigma of psychiatric problems, and increasing their level of awareness of mental health issues. They are thus enabled to access resources inside and outside their community in an optimal manner.

During its early years, it was natural for Hong Fook to target the Vietnamese as well as the Chinese populations, since most of the first refugees from Vietnam were in fact ethnic Chinese. The inclusion of Cambodians as part of the Southeast Asian groups was also logical. It is difficult to imaging how such groups could be served separately. However, it is interesting to note that the Laotians were not ready to be involved at that time. On the other hand, the Korean community is now becoming increasingly interested in Hong Fook, and has one member sitting on the board. Some other American programs also serve multicultural target populations, and we believe that this has certain advantages, including a stronger lobbying power, the sharing of limited resources, the opportunity for mutual learning and protection against ethnocentrism.

The Hong Fook model has evolved through a process of matching limited resources to the multifarious mental health needs of the Chinese and Southeast Asian populations in Toronto.

In examining the model, it is evident that the ethnospecificity of the service has been a major factor in its acceptability and effectiveness in the ethnocultural communities, where Hong Fook has a very favourable profile. On the other hand, great effort is made to maintain close involvement with the larger mental health system. Service to the clients is equally a service to service-providers, a fact that is greatly appreciated by them. Through Hong Fook, access to mainstream services by the target populations is improved. The illusory fear of parallel services among policy-makers should be allayed (Uba, 1982).

One limitation of the Hong Fook model is that, by concentrating the greatest amount of effort and resources on consultation and liaison for the more severely disabled, it has provided less treatment both for those who are not as severely disabled and for the rehabilitation needs of those who are more chronically impaired. Comparison with other programs is very instructive. For example, the Strathcona model in Vancouver offers more orthodox counselling and a wider range of rehabilitative services, including a workshop (Li, 1990). Hong Fook is already making certain changes in that direction.

Another limitation is that by attempting to be all things to all people, Hong Fook may have given itself a mandate that is too ambitious. The staff members arc limited in number; they are often severely taxed, and may at times experience role confusion. The small group of volunteers who back them up in the hard working committees also feel the strain, but this Infrastructure of support has been essential to the success of the model. For other communities with fewer resources, this will certainly be a limiting factor.

Despite such limitations, we still believe that Hong Fook is a .practical and effective service delivery model for the immigrant populations, optimizing the use both of ethnocultural resources and resources in the larger system. It has been developed specifically for the Chinese and Southeast Asians in Metropolitan Toronto, but its applicability to other immigrant communities is receiving serious consideration, and a similar program for four ethnocultural communities in Vancouver is already under way. Further evaluations of such programs will provide mental health professionals with much needed data to fill the gaps of knowledge in this field.

M, a 36-year-old Vietnamese man, was presented to an immigrant service in a suicidal state. Hong Fook (HF) was called; and hospitalization was arranged. On admission, M was psychotic, hallucinating and paranoid. With the worker's help, it was learned from the family that he had long been functioning marginally, but had become more withdrawn and irritable since his arrival in Canada two years ago. He had also been violent towards his wife and children. Schizophrenia was diagnosed and treated. Two weeks later, he was discharged to a Vietnamese family physician for follow-up. HF attempted to link him with another Vietnamese client so that they could attend a day centre together, but the plan fell through when the latter was hospitalized.

Volunteers from a Vietnamese Protestant church were brought in to visit the family and the patient. However, his compliance was poor, and he again deteriorated. The wife, who had to work and to cope with three young children, found the situation intolerable. The patient was moved to his mother's home, and HF helped him obtain welfare assistance. One weekend, he was found missing, and HF located him in another hospital where he had been admitted because of an overdose. During his two-week stay HF again facilitated the process and encouraged more support from the extended family. Family therapy was felt to be needed, but no such resource was available.

After discharge, the landlord of the mother refused to have him return there, and he returned to his wife. Again, he deteriorated and expressed the wish to go to a temple. With HF's assistance he did stay in a Vietnamese Buddhist temple for a time. Efforts to place him in supportive housing were futile, both because of his limited English and because of his own reluctance to live within a Western household. Finally, he returned home, but stayed with his mother during the day.

M's medical follow-up was then transferred to a Chinese psychiatrist. Acting as a co-therapist, the HF worker intervened actively. Compliance was ensured through close monitoring, and the family was more tolerant of the patient through counselling offered by the worker. He is still symptomatic, but remains home, and attends to his treatment.

L, a 16-year-old boy from mainland China, was referred to HF by a neighbour. He had become obsessed with cleanliness and spent hours washing his clothes, monopolizing the use of the single family washroom. He was also missing school.

A home visit was made by the HF worker together with a youth crisis team, which found him uncommunicative. Shortly after, HF learned of his arrest after he chased his father with a knife. The HF worked visited him in jail and advocated for his transfer to a youth treatment centre. There, the worker assisted with the assessment, obtaining the psychosocial history from the family. It was found that he had always been meticulous and responsible, but had been experiencing difficulty adjusting in Toronto. He also had been missing his older sister who was still in China. The HF worker tried to encourage him to cooperate with the youth treatment program, but in vain. He was discharged unimproved after two weeks.

HF then helped him enrol in an English as a Second Language (ESL) class, and linked him with a youth service that employed contract workers. A Chinese worker was found to work with L at home, while HF remained involved with the family. The youth

worker gradually managed to establish some rapport with L and arranged for him to join a ski trip and other recreational activities. However, he was again hospitalized after attacking a tenant. Schizophrenia was diagnosed, but he still would not engage with treatment. He was discharged, but the family was supported by the HF worker in refusing to allow him home without his cooperation with treatment. The youth worker found him accommodation at a youth hostel and continued to work with him.

After another five-week period of hospitalization, he again signed himself out but accepted outpatient treatment with a Chinese psychiatrist. His sister also arrived from China. L continued to improve and has moved back home. He is now attending school and working part-time.

N, a 38-year-old Vietnamese Chinese woman, was referred by her husband, who initially approached an immigrant settlement service because they were having marital problems. She was described to be lazy, irresponsible and quarrelsome. She herself also complained of insomnia, palpitation and some irrational fears.

An assessment was arranged with a Chinese-speaking psychiatrist, and the HF worker assisted in obtaining collateral data from her mother in Brampton. N was also referred to a Christian community centre that offered ESL as well as to a recreational

program for the family including the children. However, the situation escalated when the husband reported the wife to the school for hitting the children. HF called a conference with the CAS worker, the public health nurse and the psychiatrist, all of whom were Chinese-speaking. A management plan was formulated, with different tasks assigned. The HF worker became the case coordinator, and monitored the progress of the case.

A crisis occurred when the husband accused his wife of an extramarital affair. She was very shaken and was hospitalized with HF's advocacy. Because there was a Chinese nurse on the treatment team at the hospital, HF's involvement was minimal until her discharge two months later. Another conference was held, and the public health nurse assumed the coordinating role. N was referred to a workshop and also continued to see her psychiatrist.

From time to time, the couple still call HF with various concerns, which are referred back to the psychiatrist. HF has also interpreted for them when their son was assessed for behavioural problems at a clinic for child and family services.

M is a 37-year-old Chinese female who has epilepsy and a personality disorder. Her epilepsy started at the age of five. Because of explosive outbursts of temper, she has had extended hospitalizations in a mental institution in Hong Kong. However she managed to immigrate to Canada to join her family in Toronto as the last remaining family member. After living with her family for one or two years, M was asked by them to move out, as the family found it extremely difficult to cope with her illness and personality problems. M had over20 hospitalizations during a three-year period before involvement with HF.

Since her last discharge, M has been living in a boarding home where one of the operators is a Chinese. She approached Hong Fook herself, requesting that she be linked with a Chinese-speaking psychiatrist and a day program. Since then, M has been engaged in regular weekly sessions with the Hong Fook worker. She has been helped to develop understanding and skills in temper control through looking at the causes and effects of her past behaviour, with special reference to the circumstances surrounding her various admissions to hospital. At the same time, M is also being taught alternative ways of dealing with her anger and acceptable ways of expressing emotions. Through discussions and joint interviews with her roommate with whom she has had frequent fights, M has gradually learnt how to diffuse her anger by getting help from the boarding home staff and professionals, and by learning negotiation skills to resolve conflicts. As well, the HP worker has been involved ina considerable amount of negotiation and coaching of the boarding home staff to help the latter understand and effectively manage behaviour.

The worker was called to the boarding home several times at the request of the staff to help whenever M had an outburst of temper. A major attempt has been focused on working through M's repressed hostilities towards her family, whom she hates because they have abandoned her.

The worker's input has proved to be effective. One significant improvement is M's ability to prevent rehospitalizations. Although she still throws temper tantrums now and then, such outbursts are intense or frequent. As a result, over the past five years M has been able to remain living in the community. She is now happier, getting on well with her boyfriend and well-maintained on medications prescribed by her Chinese-speaking psychiatrist and family physician. She is now awaiting assessment by a vocational rehabilitation service for an appropriate rehabilitation program.

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