Best practices for social work with refugees and immigrants

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Organizations vary greatly in size, ranging from those with few or no paid staff, to those with a staff numbering in the hundreds. Some organizations are new, some old, but as a network they have the combined strength of acquired experience and strong links to the communities they serve. Larger centres with many newcomers can have highly specialized organizations, while in the smaller centres the organizations must be more polyvalent. Settlement agencies, therefore, exist in a variety of configurations:.

Monoethnic: Created by and for an ethnocultural community. Multicultural: Created to respond to newcomer needs in a specific local area. Some organizations established by one community expand to serve many. Faith-based: A response of a faith community to community need. Specialized: Focused on a specific area of need e. Serving newcomers as one part of their mandate: Organizations that serve newcomers as part of a wider community response e. The broad range of settlement services, especially second language programs, are delivered by a variety of public, private, and community-based agencies.

However, community-based immigrant and refugee-serving agencies "have a proven track record as cost-efficient, effective service delivery mechanisms. Strengths of Community-based Settlement Agencies. The strengths of refugee and immigrant-serving organizations lie in their: Settlement workers who are highly experienced, dedicated, knowledgeable and professional Long-term commitment which derives from their mission to make a positive contribution in the lives of the people served and in society. Roots in the community, which mean they are trusted and can quickly identify and adapt to changing needs.

Cost-effectiveness, since they have low overheads and benefit from significant community contributions. Accountability, since they are governed by volunteer boards of directors representing the community as a whole. Community approach, which results in a welcoming environment, personalized services and broad community participation. Holistic approach, through which the range of needs of individuals and of the community as a whole are considered. Diversity of approach, resulting in the existence of a range of different organizations from which newcomers can choose the approach that best suits them.

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Agency Challenges. Refugee and immigrant-serving organizations face challenges in a number of areas which limit their ability to fulfil their mission. Funding Inadequate funding: Funding levels have declined over the years while demand for services has increased. Limited funding keeps salary levels low which inhibits stable staffing.

Short-term funding: The lack of multi-year funding makes it difficult to plan ahead, and proves time-consuming as funding applications need to be renewed. Short-term project funding also results in a lack of stability in staffing. Complex patchwork of program-funding: Funding must be sought from a range of different funders which requires considerable administration time. Unequal power relations: Funders assuming ownership of projects curtails an agency's ability to administer projects effectively and efficiently.

Settlement services are a kind of social service, but one where the need derives from the external situation rather than the "neediness" of the client. Newcomers are basically healthy people who require some assistance in making their way in a country where "the rules of the game" are different. They encounter problems in their adjustment, and some can go through periods of acute distress, but as a group they are remarkable for their resilience. Clients' needs.

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Adapted year by year to respond to changing times, services offered today continue to be dependent on the needs of newcomer and receiving communities. As previously noted, newcomers' needs vary depending on, for example, whether they: are refugees or immigrants; are retired and joining family or young single people headed for the job market; speak English or French.

In addition each newcomer community will have its own cultural issues. The needs of the receiving community vary depending, for example, on whether the community: is small or large has mainstream services able to give appropriate services to newcomers is working to address racism and other forms of discrimination. Services meet the needs. The range of services offered is not theoretically limited -- it depends on the needs, the resources available and imagination.

There is a constant effort to improve and adapt services, but at the same time certain services have proven effective and continue with little change for decades. There are many different ways to conceptualize settlement services, especially as there has been no consensual definition of settlement services developed to date.

Language instruction , ranging from beginners to employment-related Employment services including orientation, job-search skills, job experience placement, employment counselling and placement, and specific skills upgrading and certificate programs Long-term integration through education, community development, multicultural, citizenship, anti-racism, organizational change and development. The following diagram provides another way to distinguish the variety of services available: Chart 3. Objectives, Beneficiaries and Types of Settlement Services. Within the settlement service field, there is increasingly a recognition of the need for more systematic, ongoing sharing of experiences, particularly of innovations and successes.

From these successes, we derive best practices. Best practices are those that have proven their worth and deserve to be emulated. Best practices are offered in order to: enhance efforts at improvement. The best practices represented here are by no means the last word on the subject: they represent a current understanding, which will need to be constantly updated. It is also recognized that interventions must reflect the particular realities of each unique situation.

What is a best practice in one set of circumstances may be inappropriate in another. From best practices, we can develop standards. They differ from standards -- generally agreed upon minimum norms for programs -- in that best practices constitute an ideal to which an organization can strive. We have articulated the best practices in the form of guidelines, emanating from twelve core values. These guidelines form a framework which can serve as the basis for analysis, evaluation, planning and information-sharing in the field of settlement services.

Core values: Access Inclusion Client empowerment User-defined services Holistic approach Respect for the individual Cultural sensitivity Community development Collaboration Accountability Orientation towards positive change Reliability. Inclusion is assured by: recognizing the diversity of needs and experiences e. Clients are empowered by services. Services respond to needs as defined by users. Services take account of the complex, multifaceted, interrelated dimensions of settlement and integration.

Services are delivered in a manner that fully respects the rights and dignity of the individual. Services are delivered in a manner that is culturally sensitive.

Best Practices for Social Work with Refugees and Immigrants

Services promote the development of newcomer communities and newcomer participation in the wider community, and develop communities that are welcoming of newcomers. Services are delivered in a spirit of collaboration. Service delivery is made accountable to the communities served. Services are oriented towards promoting positive change in the lives of newcomer and in the capacity of society to offer equality of opportunity for all.

Services are based on reliable, up-to-date information. Reliability is assured by: keeping information up-to-date using social research exchanging information. Over its many consultations and, particularly during the workshops and discussions for the Best Practices Project, the CCR has provided a forum for agencies to showcase their successful, innovative programs. What follows are examples of programs, projects or practices that might be described as best practices.

These programs have been self-selected by the agencies, but in reviewing their program design and delivery it is obvious that each encompasses many of the best practice guidelines noted above, as well as addressing a combination of needs. For the time being, we are providing a summary of these best practice programs. We are planning to make more detailed information about some of the examples -- and others as they are referred to us -- available on the CCR website. The programs below are grouped very loosely under the following headings taken from Chart 3 above : 20 Services to help newcomers develop the skills and knowledge to participate in society; Services to bridge between newcomers and society; Services of general nature specially adapted for newcomers or responding to their specialized needs; Services to help the host community in its process of adaptation to newcomers.

Comprehensive Initial Assessment of Immigrant and Refugee Clients A holistic initial assessment by a counsellor is conducted of incoming clients, as individuals or members of a family. The assessment includes the exploration and discussion of the following factors: stresses of migration, level of adaptation; grieving process; education and occupational background; knowledge of official language s ; literacy in first language; present employment, housing and financial situation; significant health issues; family dynamics changes in roles and relationships in family, etc.

The assessment takes place as a semi-structured interview, preferably during conversations with the client. It requires an experienced counsellor, sensitive to linguistic and cultural issues. The counsellor should be able to initiate with the client the exploration and reflection on these issues in a non-intrusive manner. It takes from one and up to three hours, in one or several short sessions, to explore relevant issues.

The investment of time in the comprehensive initial assessment facilitates the settlement counselling process in several ways. Creating an alliance to address newcomer needs In a city receiving relatively few immigrants it was recognized that students in a second language class had adjustment problems that were interfering with their ability to learn. A group gathered to look for solutions. They decided not to form another service agency, but rather an alliance of interested individuals, with backgrounds in mental health, immigrant services, community development, counselling and literacy.

They gave themselves the mission of providing educational support for the mental health and emotional needs of recent immigrants as they adjust to life in the city, to educate recent immigrants and the people who provide services to immigrants about the settlement and integration process immigrants often experience, and to provide such services in a community-based, supportive, culturally sensitive manner.

They developed a brochure, a video and a manual for a simple model of immigrant adjustment. Establishing effective partnerships with all language service providers and advanced education institutions The immigrant-serving organization works in collaboration with the various language service providers in the community in order to plan service delivery.

Students are referred to the appropriate institution: those with advanced academic qualifications to university language programs, those requiring basic to intermediate language training or language training for non-academic purposes to community colleges or immigrant serving agency language programs, those with childcare needs to immigrant serving agency program as it also offers childcare programming.

Married students where both individuals are learning English may take language training from two different types of institutions depending on their respective needs. Institutions also consider issues such as ethnic conflicts within the country of origin when placing students from these areas. All collaborating institutions agree on accreditation of staff and entrance requirements of students. The academic institutions may offer in kind support to the childcare programs offered by immigrant agency e. Newcomers' Employment Bridge Project This employment project, launched by a coalition of agencies in one city, focuses on opening doors with potential employers.

It responds to the problem of unemployment and underemployment and seeks to address a gap in services to newcomers seeking employment. Newcomers are referred to the project by participating settlement agencies. They are helped to identify their employment needs and where to get related assistance. Collectively they are marketed to employers in the region. They are assisted with making contact with employers and obtaining volunteer placements to gain Canadian work experience and matched to mentors in their field. They also receive encouragement and moral support in their job search.

Assisting clients in career planning Centralized language assessment and career assessment service are provided to identify client need, assess current abilities, assess prior learning and education, and assist clients in establishing career goals and developing a plan to establish recognition of credentials. The combined training and work placement components total ten weeks, with additional time required for on-going follow-up and counselling.

Classroom instruction encompasses employment readiness seminars, basic computer skills, TOEFL preparation and post-secondary readiness. Students are then marketed to local employers and assisted with making contact with them to secure volunteer work placements. Maintaining effective, mutually productive partnerships with employers The organization maintains a database of clients and employers. Private corporations and government agencies are offered assistance in meeting their equity targets. They are offered a referral service for clients with transferable skills and in-house cultural diversity training.

This is considered as a long-term partnership strategy. Initiating and influencing institutional change while empowering communities Three suicides within a specific cultural community led to families and communities in crisis. An immigrant-serving organization contacted bereavement crisis intervention services but no one spoke the community's language. The families were referred to a professional who spoke the language but they did not show up for their appointment. Then a meeting was organized with the affected community.

They determined that they wanted training for their community. Two workshops were conducted from which two individuals were invited to participate in further training. Twelve individuals have now been trained to be caregivers within their own communities. Indepth research was also done to determine services that are inaccessible.

This response offered a two-prong solution: 1 it helped to support the existing network by identifying where they needed to change; 2 it provided the necessary resources for the community to access services. Community Resource Program An organization in a city with relatively few services for newcomers developed a project to empower the ethnocultural communities by providing them with information on services available in the community and how to access them, by providing culturally appropriate services to new arrivals and by promoting the conditions for community development and community-based projects.

At the same time the project aims to provide education and cultural sensitivity training to mainstream service providers.

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Members of a number of different communities are given training and then offer services to their community, acting as Community Resource People. They are paid for the services they offer. General Services Family Counselling Program Settlement counsellors were recognizing that among their clients were immigrant families in crisis. However they lacked skills in family counselling, while existing family counselling services were inaccessible to clients for linguistic and cultural reasons. An immigrant-serving organization responded by working with a family therapy institute to develop a multiple partnership model for the delivery of linguistically and culturally appropriate family counselling services.

A professional family counsellor, on staff at the immigrant-serving agency, works in conjunction with settlement workers, who have received extensive training in family counselling theory and practice. The settlement worker generally remains the principal counsellor, but receives support through bi-weekly reflective case reviews from the family counsellor who may also sometimes sit in on a session. In difficult cases, the family counsellor may become the principal consultant.

This model combines the cultural skills of the settlement worker with the counselling skills of the family counsellor. Health Programs Public health education An immigrant-serving organization works together with a public health agency on public health education for clients. Materials on health issues are translated into clients' languages. The issues are introduced into language training classes and a guest speaker is invited.

Students are taken on site visits. The public health office provides written materials and resource personnel i. The immigrant-serving agency provides cultural diversity training for the public health agency workers. Education and growth group for immigrant women An immigrant-serving organization found that due to changes in funding criteria it would have to stop giving individual counselling to some of its clients. These women were continuing to seek these services several years after arrival in Canada because of their isolation and low level of integration.

They were met individually to explain the situation and offered an opportunity to participate in a group. Eight women formed the group which met for nine weekly sessions of 3 hours each, held on Fridays since it would not matter that the family got home late as the children did not have school the next day.

Day care was provided for the children. The objectives of the group sessions were 1 to create a network of mutual assistance between the participants; 2 to increase their independence; 3 to promote their integration; 4 to reduce their isolation. They used feminist and intercultural approaches and focused on 3 principal themes: plans for migration; cultural shock and the migration process. A guide has been developed presenting the approach which can be used with any group of immigrant women experiencing difficulties with adaptation.

Cultural Brokers for Minority Women and Families A project designed to enhance perinatal care and family support within cultural minority communities has developed a practice of "cultural brokerage" that is relationship-based, holistic and oriented towards community development and advocacy. Nine women from six communities act as Multicultural Community Health Developers MHCDs , providing culturally and linguistically relevant care and support to minority women and children perinatally and into early parenthood.

A coalition of representatives from health, social, settlement, education and family service institutions work with the MHCDs to increase understanding among the institutions of cultural brokerage. Women's Information and Support Line A women's information and support services hotline is organized and run by volunteering women from a specific community. It seeks to address settlement issues and break isolation among women from the community who cannot access mainstream services.

Services include crisis intervention, accompaniment and interpretation, information on accessing services and referrals. The twenty volunteers have all received training. Youth program A one-day program introduces young people to issues of law and politics by taking a youth group to visit a prison, meet with two police officers one man, one woman and talk to an MP. Assisting youth in becoming oriented to Canadian culture The program focuses on youth who have been in Canada less than 3 years.

They are divided into two groups: years and years. Guided group activities provide orientation to Canadian culture. There is a focus on peer relationships. Parents and the community are involved. Relationships are created with other youths, thus encouraging cultural sensitivity in both groups. Focusing on parents and youth In response to growing intergenerational conflict, a settlement organization established a program in which parents and youth each meet for four sessions separately to address issues affecting family life.

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The final session is a combined celebration with youth and their parents. They examine their different perceptions of issues. Intergenerational Program In a program to reduce the risk of adolescent maltreatment and delinquent behaviour among first generation immigrants, a skills-building and support program targets immigrant parents and adolescents simultaneously.

Facilitators are drawn from mainstream Canadian and the focus ethnic group population. Program components include parallel parent-adolescent skill-building groups, parent help groups, peer support groups, cultural celebrations, recreation program and activities, ESL tutoring, drop-in resource centre, counselling, and home visits. First language facilitation was available for parents. Process and outcome evaluation procedures were built into the program design. The program was also developed as a collaborative bridging model between an immigrant-serving agency and mainstream service providers; the partnership was also evaluated.

Summer Daycamp Program An organization runs an eight-week summer program for immigrant children, with emphasis on English language activities. This program offers children the opportunity to participate in fun and stimulating activities during their summer holidays, while allowing parents the opportunity to continue their attendance at ESL school during the summer. Newcomer guides Many organizations produce booklets that direct newcomers to community resources and are regularly updated.

For example, in a mid-sized city, a settlement agency has compiled a manual which gives newcomers an overview of life in their new community. The booklet helps them attain greater independence, by providing information on various aspects of life, including education, transportation, the medical system, shopping, social activities, etc. Transportation loan support repayment service Many government-assisted refugees arrive with a loan debt towards the federal government for their travel to Canada.

Since newly arrived immigrants seeking to repay the loan often have not established a bank account, they must use money orders or cash which is risky. The immigrant-serving organization meets with the client and establishes a repayment schedule that is sensitive to the ability of client to pay. Clients bring to the agency cash, money order, or cheque payable to agency on scheduled payment dates.

Receipts are given to clients. The money is collected and the agency then issues one cheque to the government with a listing of client contributors names and government identification IMM numbers and amounts to be credited against client account.

Conducting regular planned performance appraisals of staff A clear job description is provided, describing the workers' tasks and duties as well as how the worker relates to the agency as a whole. Annual pre-planned performance appraisals are conducted. The appraisal includes an opportunity to establish personal and professional goals.

Each staff member is assigned one community activity or commitment to be involved in for external exposure. Reporting on these activities is done within the division and where appropriate to all staff at the monthly staff meeting. Offering professional development to volunteers An immigrant-serving organization worked with other agencies in the community to provide shared training for volunteers, with a view to increasing attendance and revitalizing the training programs.

This shared training has several forms, including the organization of a one-day volunteer conference on an annual basis. It has grown in popularity with eight agencies now involved and approximately volunteers expected to attend the next conference. Participating agencies draw on their own resources to provide experienced presenters on a range of topics. Since all participating agencies are involved in social services but not immigrant-serving alone, the list of conference topic offered is broad and varied, giving volunteers training opportunities which no agency alone could provide.

The one day conference is offered at no cost to volunteers. As one of the participating agencies is an educational institution, there is no cost for location for the event. Lunch is served at no charge. The high attendance speaks of its interest and value to the volunteers. Inspired by the success of this type of training event, a training conference was planned for volunteers in language learning. The third annual conference is expected to involve seven different organizations and approximately volunteers. Shared training is also offered to volunteer language tutors on a monthly basis.

Three organizations share in this training, which means that each organization's staffing resources are required only once every three months to host a training session. The volunteers benefit by having regular training and by meeting other volunteers both within the organization and from other organizations. Media Enhancing Media Awareness Recognizing the importance of the media in building the public's perception, the agency makes itself available to the media through interviews and writing articles for submission.

A "Salute to the Media" banquet is held, with the immigrant-serving agency paying tribute to the contribution of media in building public perception and giving awards for accuracy in reporting. We have approached this document as a "work in progress". Just as settlement is an ongoing process, so are efforts to provide the best possible settlement services.

The best practices offered are intended as a contribution to the dialogue on maintaining and improving standards. We have focused our attention on the settlement services offered by refugee and immigrant-serving organizations. Important as they are for many individuals and communities, they constitute only one part of the services offered. Families, friends and ethnocultural communities informally organized also provide essential support to newcomers in the process of integration. Settlement services, whether formal or informal, are in turn only one factor in determining the success of newcomer integration.

Institutions, such as schools, hospitals, police, justice systems, media and government departments, all play a key role in either helping or hindering integration by the degree to which they adapt to the diversity of the clients served. Refugee and immigrant-serving organizations can help such institutions recognize the need for adaptation and make the necessary changes, but they can only be effective insofar as the institutions are willing.

Another key determinative factor for successful integration lies in government policy towards newcomers. Policies that give refugees and immigrants security and a sense of belonging help to promote integration. Conversely, policies that keep families separated, delay permanent status or leave communities feeling threatened make integration difficult or even impossible. Attitudes among the general population also have a significant impact on integration: they affect newcomers' relations with their neighbours, with their colleagues at work, with their fellow students at school, and with anyone they encounter in daily life.

This is why most refugee and immigrant-serving organizations count public education and anti-racism awareness-raising as essential aspects of their work. Media attacks on newcomers or xenophobic comments from a prominent person are not only very painful for refugees and immigrants: they also undermine efforts made to create a welcoming environment. Within the scope of their work too, there are challenges which can affect whether they are able to implement best practice models. Levels and conditions of funding limit what can be done.

Lack of coordination between organizations can lead to duplication or gaps. As we write in early , much about the future of settlement service delivery in Canada remains unclear. The consequences of the proposed devolution of funding administration from the federal to the provincial governments are yet to be seen. This context presents an important opportunity to develop national standards for settlement services, a project recognized as a priority by the Canadian Council for Refugees. National standards would be a tool to ensure that newcomers could be guaranteed certain minimum levels of service wherever they settled in Canada.

They would help those involved in the administration or delivery of settlement services to define and focus on the essential core of services as a minimum on which to build. Another hope for the future is the creation of a national clearing house for information on settlement services. Such a clearing house would make use of the communications potential of the Internet.

An ability to exchange information on what works well and on new initiatives and to quickly find answers to questions would assist those providing settlement services to be more effective. An advantage of the Internet is of course that it allows easy communication not only from province to province within Canada but also internationally. Provincial, regional and national associations have a key role to play in the sector's continuing efforts at self-improvement, through coordination, training, information-exchange and policy development.

They also serve as a means of connection with other sectors, helping to ensure that newcomer issues are included on relevant agenda. In the realm of immigration and refugee policy, current proposals suggest that radical reforms are likely in the future. The recently released Immigration Legislative Review report outlining the proposals will be the subject of much debate in the months to come. It is however interesting to note the emphasis given to integration as an essential element of a successful immigration program. The report identifies a series of principles to undergird the program which show some overlap with the Best Practices Guidelines: accessibility, responsiveness and accountability feature on both lists.

Partnership and consultation are explored in some detail in the report, with recommendations to make them more meaningful in the future. In the meantime, of course, settlement services will continue to be offered to newcomers and to the communities welcoming them. The Best Practices Guidelines and examples in this document will, we hope, be a useful tool to those offering the services and to others interested in understanding them.

Borisenko, Laurel and Virginia Sauve. October 22, unpublished. Bev Brawley. Developing Standards of Practice for Settlement Services. National Settlement Conference. Montreal: CCR, , 59 p. Citizenship and Immigration Canada. Ottawa: CIC, November leaflet. Ottawa: CIC, November , 33 p. Change and Management of Settlement Programs for Newcomers. Ottawa: CIC, n. Ottawa: CIC, June 6, , 33 p. Citizenship and Immigration Canada, Ontario Region.

Settlement Renewal Consultations, Round Two. Ervin, Alexander. Final Analysis and Recommendations. Prepared fro Citizenship and Immigration Canada, Halifax, January , 15 p. Vol 5 2 , April Kage, Joseph. Montreal: Eagle Publishing, MWB Educational Consultants.

Treating Trauma in America's Refugees

Neuwirth, Gertrud. Settlement Renewal. Developed by Janis Galway. Proulx, Monique. Le Centre social d'aide aux immigrants. Interculture, Cahier n , Vol. XXVII, printemps Regroupement des Organismes au Service des Nouveaux Arrivants. Revue Univers. Usha George, Ph. Michalski, Ph. We have approached this report as a living document, the beginning or continuation of a dialogue among immigrant and refugee-serving agencies and all the organizations and individuals committed to assisting the integration of newcomers to Canada.

There are additional successful programs to discuss, more solutions to share, many challenges to explore. Many of the umbrella associations are in the process of developing or expanding projects designed to share information on settlement issues. We invite you to continue the dialogue through ongoing discussions at conferences, workshops and on the new medium, the Internet. Listed below, arranged by region, are links to the major immigrant and refugee umbrella organizations, from which you can link to many other organizations, agencies, and government departments and divisions.

At the same time, the need to support immigrant and refugee families through the complexities of mental illness demands that innovative approaches and improved standards for transcultural and trauma-informed mental health care are put in place. This paper explores the challenges and recommendations to improve assessment protocols to meet the mental health needs of vulnerable immigrant and refugee populations with trauma histories.

Community forums were held to identify the challenges experienced by immigrants and refugees in mental health services in London, Ontario. These forums brought together people from across community and health care settings, including representation from immigrant settlement organizations, community services, educational institutions, community mental health groups, hospital representatives, and people with lived experience.

An advisory committee was established with over 30 representatives from community stakeholders and organizations involved in immigrant and refugee services from both community and hospital mental health services, public health, social services, child welfare, settlement, education sectors, and additional members with lived experience. This committee regularly provided feedback on the research findings and practice recommendations for transcultural mental health care. A range of gaps in access to culturally appropriate mental health services that meet the needs of immigrant and refugee communities in the London and Middlesex area of Southwestern Ontario were identified.

Problems such as long waiting times, unavailability of interpreters, lack of trauma-informed care, and poor coordination between hospital and community-based services were some of the key issues that impeded the provision of effective, coordinated, and integrated mental health care. In , a quality improvement process was initiated by an academic health sciences center in London, Ontario, to improve the mental health outcomes of immigrant and refugee children and families, through service changes in the hospital as well as enhancing collaboration between health and social service providers in community-based settings.

To identify broader strategies for system improvement, exploring skills and gaps among health care providers was an important first step. This paper presents findings from a baseline assessment to gauge the current practices and experiences in providing mental health services to immigrant and refugee communities. The study captured a range of experiences among mental health care staff, aimed at understanding the current challenges and promising strategies of providing trauma-informed and culturally appropriate mental health care for immigrants and refugees, from assessments through treatment and recovery.

A baseline assessment of mental health services for immigrants and refugees in London, Ontario, was completed in The study included semi-structured interviews and focus groups with health care providers and managers working within the continuum of mental health services both in the hospital system and hospital-affiliated community care settings. Respondents were asked about their experiences working with immigrant and refugee patients and families in mental health care.

Questions included details around knowledge, skills, protocols, practices, education, and partnerships with community-based services. The purpose of the interviews was to develop a baseline of current attitudes, knowledge, and skills around culturally sensitive and competent practice within mental health and emergency care and to identify some of the main challenges that care providers were facing in transcultural mental health care contexts.

Through a process of stratified purposeful sampling to assess experiences in providing transcultural mental health care, our respondents included mental health and emergency department physicians, psychiatrists, psychologists, residents, nurses, social workers, child and family therapists, employment and life skills counselors, occupational therapists, support staff, and organizational and program leaders within mental health. A total of 26 qualitative interviews and three focus groups were completed totaling 40 participants. The interviews examined both positive and negative experiences with immigrant and refugee patients; knowledge and training regarding protocols and services; and recommendations on ways to improve mental health services for immigrant and refugee patients.

Interviews and focus groups were recorded, transcribed verbatim, and coded in NVivo, using a grounded theory approach [ 22 ] to identify thematic nodes and sub-nodes based on the participant transcripts. There were 15 distinct nodes related to assessments, ranging from the type of assessment tools, to the challenges of the assessment process with this population. This paper presents and discusses the key findings from the themes around assessment practices, culminating in recommendations for improved practice based on standards such as the DSM cultural formulations, combined with local perspectives on strategies for advancing transcultural, trauma-informed mental health care.

The results from this study demonstrate that standards of practice for transcultural care are not in place across mental health services in London, Ontario, despite the existence of evidence-based recommendations in the DSM This section outlines current practices, approaches, challenges, and recommendations shared by mental health care providers and program leaders in addressing the mental health care needs of immigrants and refugees. Respondents shared that there was no common process guiding transcultural assessments in mental health. Although the DSM-5 provides a valuable framework for explaining cultural factors in the presentation of mental illness, there are financial, bureaucratic, ideological, and political barriers to making meaningful changes including implementing best practice guidelines across a large hospital.

Patients also have varied pathways into mental health care, including the emergency department, direct admission, and referrals from doctors or community agencies; different assessments are carried out that provide different information. As one occupational therapist explained, regardless of how a patient accesses mental health services, background patient information is. Not always sent with the referral.

If the referral comes from there, hopefully there would be some appropriate information that would get sent about the client. One of the reasons that there is often limited information on both the health and social history and beliefs of immigrant or refugee clients is that there are no expectations that providers use the DSM-5 in their assessments. Care providers select their assessment process, and many are uncomfortable and unsure of what to ask immigrant and refugee patients.

As one social worker noted,. This discomfort can prevent important issues being explored with clients, especially when they have a different linguistic, cultural, or religious background than the care provider. Respondents noted that there was no mandated cross-cultural assessment tool across mental health services.

Few are familiar with the section on cultural psychiatry in DSM-5 and the cultural formulation in the DSM-IV, and those who are, felt they needed to collect more detail for a robust transcultural assessment. Such information in referrals could help providers prepare for the appointment by booking an interpreter or arranging for religious accommodation. A reason there is no consistently used transcultural assessment tool in mental health was attributed to the difficulties in applying the DSM objectively across all situations.

As one psychiatrist stated,. Some providers include cultural and language assessments, but in general, these are used inconsistently and lack comprehensiveness. The Montreal Cognitive Assessment MoCA is a brief cognitive screening tool available in many languages; however, it lacks a transcultural approach. Participants noted that these yes or no questions from the O-CAN would not elicit the information needed to inform a culturally appropriate response. Further, it was noted that the appropriate timing of questions should be taken into consideration.

One respondent noted,. And it may be so traumatic sometimes that bringing that up right now is counterproductive. If patients are in crisis when they meet the provider, questions about trauma may not be productive until the patient is more stable or a relationship of trust has been developed with the care provider. The lack of standardized assessments for transcultural mental health leads care providers to adapt practices on an ad hoc basis. For some this meant doing a shorter screening at triage, a brief cognitive assessment with an interpreter if needed , and determining the religious requirements for either a male or female health care worker HL1.

One respondent noted the need to tailor the assessment based on cues from the family, such as delaying questions around sexuality until they had established trust HL2. The complexity of assessments with an interpreter also requires adaptation and adds the potential for misunderstanding. Many respondents spoke of the importance of training for working with interpreters, although this training was not available to them.

As one program manager in mental health care explained,. So you know, in the emerg [Emergency Department], where I think they use them [interpreters] quite frequently, you learn by doing and you learn from a more experienced nurse or whatever. I think it should fan out across the organization where it might be used less. The level of skills of the care provider and the interpreter, as well as how they work together can affect the entire assessment process.

Despite an overall dearth in training and formal processes for transcultural assessments, decision-makers and providers rely on their own knowledge, skills, and intuition, with many emphasizing a generic patient-centered care approach. All respondents highlighted the need for a more encompassing approach to transcultural assessments.

Provider wanted details not only about their past, but also about what they are currently dealing with, such as a family break-up or resettlement difficulties. As a physician leader in the emergency department explained,. A nurse case manager noted that through exploring personal histories of immigrants or refugees accessing mental health services:. We get a really thorough psycho-social history on the person. And if that person lived through a war during that time that can be significant. Or maybe they had really good things happening during that time and we need to tap into that.

But getting to know who the person is, is fundamental in our care plans HL1. Care providers noted that collecting the story allows them to get to know their patients, their roots, their work experience, their cultural practices, their religious beliefs, and their migration journey, including any potential traumatic experiences HC10, HC8, HL7. Knowing this type of information would allow for a patient-led approach for the care plan, tailored to each client. In addition, health care providers noted the lack of time as a barrier to a full assessment.

Other care providers highlighted that dealing with historical traumas often has to be postponed in order to focus on immediate needs and goals. Although many immigrants and refugees may have deep traumas, they also have tangible immediate challenges in their adjustment to life in Canada, navigating housing, school for their children, not knowing where to get information they need to establish themselves HC One emergency department physician was clear that the assessments for immigrants and refugees, especially those with limited English skills, needs to first focus on those basics:.

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Are there kids? Did you eat today? What did you eat today? How are you eating? And all of those things as a screening tool — for me, screening patients is sort of the first thing. Once I screen them, you very quickly know who you need work on HC Multiple providers emphasized that understandings of mental health are culturally embedded, and that the way we label psychological disorders is culturally biased HC11, HC Another social worker also echoed this perspective:.

So is that a negative thing to them? Someone who is psychotic from one background might look quite different than someone who is psychotic from a different background. The assessment process itself can be a tool to explore cultural interpretations of mental health. As one psychologist shared,. The assessment really is more on trying to get their understanding of those issues because different cultures have different understandings of mental health issues.

Trying to get those to be appropriate This perspective resonated in the comments from a social worker:. I…have learned about, you know, culture in Iran…that might cue me to ask certain questions, right? Acknowledging cultural difference is an important beginning for effective transcultural care, yet it is important not to make assumptions based on these cultural differences.

Instead, respondents recommend open-ended questions that allow the patient to lead the discussion results in more accurate assessments HC2. The level of acculturation to Canadian society was a key factor in the ability to communicate and articulate health needs HL3, HC2. A health care leader shared the story of an immigrant girl who initially presented for belly pain, but only years later could explain that she was being sexually abused:. And a little bit more empowered and now could bring the issue forward HL3. That somatic presentation was noted by some respondents as more common in women and girls in some cultural groups HC9.

Understanding the importance of cultural factors in experience and communication of health concerns should not lead to assumptions about its relevance for everyone from that cultural group. As a social worker stated, cultural education is important, but interactions should be focused on exploration:.

Just how to ask questions, not specifically that you have to be aware of every cultural process. Because I find that I get to know a lot about my patients, about asking them what their interpretation of their culture is. Because, again, it means different things to different people. The best way to avoid misunderstandings is to take a patient-led approach to interpreting cultural meaning, allowing patients and families to guide the role of culture in their healing process.

Family-based care is a valuable approach for mental health treatments with immigrant and refugee patients. Understanding the experiences that families have been through is an important beginning for the mental health assessment. Pre-migration experiences shape family norms and thus need to be understood by care providers. Community service sector and resettlement agencies were identified as facilitators of understanding the pre-migration experience:. I found it very helpful to have those other representatives from the community there that were aware of the story and also kind of aware of mental health concerns in that population.

A social worker noted the need to be aware of family perceptions about mental health to effectively engage in patient care:. Like what, you know, what are some of the family dynamics that are going on here that might be influencing the situation, being very curious about how people are understanding this themselves,…how are they understanding themselves and this experience. This family-centered approach includes being able to understand how care plans and therapies impact the family.

A social worker explained that it is possible to cause harm even when one has the best of intentions:. But the damage was done HC9. A social worker explained that sometimes the focus is on rebuilding family. A refugee woman was devastated and depressed when her husband left her not long after moving to Canada. I did the assessment [of her] family of origin. We - she was able to reconnect with her cousin. Through this reconnection, the patient was able to strengthen her wellness plan and shifted her focus to one of hope for the future.

Other providers noted that many immigrant and refugee families experience trauma that is collective, layered, and intergenerational. And then what - how they got here. The experience of trauma is a significant challenge in many immigrant and refugee families. A social worker spoke to this challenge, noting that families experience trauma before, during, and after migration.

Health care staff may recognize. But not necessarily the specifics of how they are going about integrating into the [local] community and finding connections here. Care providers spoke about the need to support patients to process their trauma, but to approach this with caution:. Not necessarily, right. So trying to understand, get some understanding of their experience. Providing refugee patients appropriate opportunities to tell their trauma story was seen as key to the healing process, as long as it is approached carefully.

As one psychiatrist explained:. Like the actual trauma, I think maybe that day was the first day of her healing HC Care providers need to be able to share clinically relevant information from these patient trauma stories with the care team, so the patient does not need to keep retelling their traumatic history. The complexity of trauma among refugee populations demonstrates the value of an interdisciplinary team approach, as one psychiatrist asserted:. Like, we — we need to find some way to streamline it, to just get the treatment started instead of, you know, seeing different — different people.

So I really see, you know, a specific…trauma team that has the cultural sensitivity, but also has the interdisciplinary part. Through recognizing these complex challenges, respondents identified the need for a trauma-informed coordinated team-based model of care. Overall, respondents found assessments with immigrant and refugee populations challenging for multiple reasons, such as the need to work with interpreters, different perceptions of mental health, complex trauma, and the lack of time for completing the interview, which takes longer in these situations.

In addition to through adopting a flexible, family-centered approach where assessments included rich descriptions, participants highlighted the need for a standardized mental health assessment process for immigrant and refugee patients in mental health. They also noted that assessments could only be effective if an interpreter is available. The respondents emphasized the need for a process or tool that integrates the interpreter and ensures that care providers are trained in using interpreters.

The assessment tool could allow staff autonomy and judgment, while providing support for the specific challenges of immigrants and refugees. Standardizing assessments would help staff who might not have the training and experience FG1 , and overall would improve the quality of care for immigrant and refugee patients HC2.

There was an equally strong consensus around the need to be flexible and adaptive. Care providers need to be attuned to potential trauma triggers, and to ensure that the patient feels ready and safe with the providers and the environment. As a nurse leader noted about hospital-based care:. This is a very busy area, a very active, you know, environment for them to come into. Whether there be may be a separate area that is, you know, less stimulus, more isolated…They feel that if they are going to come into hospital to be assessed that they would feel more comfortable without the loud overheads going off and [security]…doing their rounds through there randomly and setting off a lot of the PTSD stuff HL1.

Another important recommendation focused on building the knowledge and capacity of health care staff and organizations. Improving provider knowledge and organizational capacity also emphasized the value of training in trauma and transcultural informed models of care, interpretation use, and practical forms of interactive education HC8, HC6, HC2.

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A mental health care leader emphasized the importance of a flexible patient-centered approach for improving assessment processes for transcultural, trauma-informed care with immigrants and refugees:. Not putting your foot in your mouth either, but you know, being curious enough just to ask a respectful question about how is the best way for me to work with you? I see it as just being patient-centred HL8. Our study has demonstrated many complex issues to consider in the assessment of mental health disorders in immigrant and refugee families.

Although current practices are inconsistent, respondents emphasized the need for a thorough yet flexible and adaptive approach that explores differences in cultural interpretations of mental health. The DSM-IV and DSM-5 provide guidance for practitioners, but their focus on diagnoses, while important for psychiatry, may not provide relevant information for providers in other areas of mental health who do not diagnose, nor have the time for the cultural formulation assessment.

Questions within the DSM documents can provide valuable guidance, but it does not fit all clinical settings or needs. To ensure a high level of competency and responsiveness to cultural difference, health care providers need supports and tools to increase their comfort in having these difficult conversations [ 15 , 24 ]. This includes training in the use of the cultural formulation, as well as time allotted to carry it [ 10 ].

Care providers seem unaware of the materials they can access to increase their skills in transcultural care. As argued by Hebebrand et al. In order to ensure care providers do this preparatory work, organizations should provide continuing professional development opportunities in transcultural skills. It is possible to improve the comfort of health care workers to engage in difficult conversations in a culturally competent and responsive manner, through education and resources.

Unfortunately, research has shown that staff working in a hospital setting are often not able to get professional development time to participate in such training [ 12 ]. Ferrari et al. Improved access to and use of transcultural assessment tools would be valuable in the context of immigrant and refugee mental health care. Understanding the issues that shape their mental health could improve the appropriateness of the approaches used.

Knowing the potentials of re-triggering trauma would ensure that care providers are more sensitive to these issues when taking a narrative history. Indeed, research on cultural formulation by Kirmayer et al. Transcultural trauma assessments are more time consuming and need to be supported organizationally. As Ferrari et al. Another benefit of transcultural training and tools is to develop understandings of how mental health can be informed by cultural values.

As Adeponle et al. Such assumptions can lead to misdiagnoses, especially in mental health, leading Sundvall et al. Each client will interpret their mental health framed through their own unique perspectives; allowing them to explain their experiences can prevent culturally biased assumptions from providers.

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As Kirmayer et al. Choosing appropriate processes for exploring past trauma is also key in supporting effective assessments and care oriented to the refugee experience [ 27 , 28 ]. Since the mental health problems of immigrant and refugee patients are often based in traumas affecting all family members, many studies emphasized the appropriateness for a family-based approach [ 1 , 29 — 38 ]. Supporting the family and understanding their collective experience of mental health and trauma is a valuable approach in transcultural care [ 39 ].

Multiple studies echo our findings that successful treatment plans are most effective if families can play a supportive role in the healing process [ 30 , 33 , 34 ]. Weine et al. Cultural norms of male dominance can be a barrier for women accessing the services they need, so attention needs to be paid to the relationship dynamics to ensure all members are safe from abuse within the family [ 11 ].