1. Challenges and advancements in providing access to mental health services for diverse patients in Canada Lola Bendana translations@multi-languages.com

2. Prepared for: Scottish Universities Insight Institute Heriot-Watt University University of Strathclyde Psychiatry Unit, St John’s Hospital Mental Welfare Commission for Scotland April 9, 2015 - Glasgow

3. o Immigration in Canada o Why Professional Interpreting Services? o Provision of Services o Challenges o Advances 3Multi-Languages Corporation

4. Immigration in Canada New patterns of immigration poses new challenges for the delivery of mental health services. For the first 100 years of Canada being formed as a country, immigration came from Europe. 4Multi-Languages Corporation

5. 5 Since the 1960’s there has been a shift in immigration sources. In Canada, the proportion of the population that requires an interpreter for health care is at least 1 in 50, and possibly much higher. Over 100 languages are spoken in main cities Toronto, Montreal, Vancouver

6. 6 Very diverse situation from province to province. Issues are accentuated in smaller communities. Some communities are not well prepared for diverse immigrants. Since 1990 Canada has accepted approximately 230,000 immigrants per year, mostly from countries where English is not the first language.

7. 7 Ontario is the most ethnically diverse province in Canada - its residents speak more than 200 languages and dialects. Over one quarter of the population has a mother tongue other than English or French (Statistics Canada, 2007). Immigrants make up 41% of the population in the Toronto Central Local Health Integration Network.

8. 8 Why Professional Interpreting Services? Effective communication is crucial to providing quality health care. Qualified interpreters ensure that people who are not fluent in English or French have fair access to high-quality mental health services.

9. 9 Language barriers pose limitations to informed consent, can delay needed services, lead to unnecessary testing, lengthen hospital stays, increase emergency room use, interfere with follow-up care and waste scarce resources by tying up health care providers' time. (TC LHIN, 2010).

10. 10 Interpreter services have particular importance during mental health assessments and counselling sessions. Even when patients know basic English, their command of it may not be adequate to allow for mental health assessment or for detailed information gathering, particularly when they are in distress.

11. 11 Inadequate communication can have significant clinical consequences, including (Miletic et al, 2006): o underestimation or overestimation of the severity of mental health problems o failure to correctly identify the type of mental health problems present o diagnosis of mental health problems that are not present.

12. 12 Provision of Services: Canadian Universal healthcare o o Equal access to mental health services to all Mental Health Programs offered at: o o Family medicine clinics o o Hospital Psychiatric departments o o Community health centres, etc.

13. 13 Provision of Services: Modalities o o Face to Face o o Video Interpreting o o Telephone Interpreting

14. 14 Challenges: Lack of culturally and linguistically appropriate mental health services further contributes to stigmatization and marginalization of ethno-racial/cultural communities exposing them to additional risks of developing mental health problems.

15. 15 Challenges: o o Mistrust was identified by some studies as a major barrier to receipt of mental health services by racial and ethnic minorities o o Vast spectrum of beliefs about mental health model and treatment o o i.e. susto

16. 16 Challenges: o o Culture divide –stigma o o cultural barrier as important as linguistic barrier o o People hesitant to ask for help o o Lack of recognition of language as basic human right

17. 17 Challenges: o o Lack of standard policy or processes o o Wide difference in provision of services through the country, hospitals that fully engaged only professional interpreters to those that still use the services of ad- hoc interpreters and family members o o Different training in different provinces o o Smaller communities can’t fully abide by national standards o o Video/Telephone interpreting

18. 18 Challenges: o o Funding o o Lack of knowledge of the health system and how it functions o o Lack of understanding from families (partners in the care and treatment)

19. 19 Challenges: o o New immigrants/refugees o o adaptation issues o o job changes o o family dynamics change - younger members adapt better o o Finances o o Discrimination o o PTSD in case of refugees o o fear of psychiatry

20. Barriers identified by immigrants include: o o fear of speaking English o o suspicion of authority o o isolation and sense of being an outsider o o reliance on children to find accurate information o o lack of familiarity with Canadian information sources o o cultural differences o o absence of knowledge of how to ask for services 20Multi-Languages Corporation

21. 21 Sample challenges Cognitive examinations In the performance of a cognitive examination, it is important that the interpreter refrain from giving hints or extra instructions to the patient that may defeat the purpose of the test. For example, the “serial sevens” test is a test of concentration and memory. The exact instruction varies, but often it is "Take the number 100, subtract 7, and keep subtracting 7 until I say stop." If this statement is interpreted as “What is 100 minus seven? [wait for answer] … Please minus seven again … minus seven again …,” the interpreter is essentially reminding the patient what to do and therefore limiting the ability of the clinician to complete an accurate diagnosis.

22. 22 Sample challenges Roma population: o o oral language o o concept of time o o “getting them to understand procedures” o o Lack of engagement and participation o o Feeling of being discriminated

23. 23 Sample challenges Body language: o o Patient not looking at doctors face could be misunderstood o o Head positioning o o Use of silence o o Smile

24. Advancements Professionalization process o o Development of the Canadian National Standards for Community Interpreting Services NSGCIS o o Development of a standardized post- secondary training for interpreters in Ontario which is now available to other provinces online 24Multi-Languages Corporation

25. Advancements Canadian Coalition and provincial coalitions such as the Nova Scotia Coalition and the Ontario Coalition for interpreting services Recent creation of a multi tier-accreditation system for community interpreters in Ontario 25Multi-Languages Corporation

26. Conclusion Lack of public awareness about mental health and stigma against linguistically diverse population suffering from mental illness are wide spread problems in Canada. There have been several advancements over the last 20 years to provide better access to mental health services to linguistically diverse populations. 26Multi-Languages Corporation

27. Conclusion In the future, the country needs to develop standardized policies to fully support patients from linguistically diverse communities so they have equal access to healthcare and public services. 27Multi-Languages Corporation