Division of Social and Transcultural Psychiatry, Department of Psychiatry, McGill University, 1033 Pine Avenue West, Montréal, Québec, Canada, H3A IAI. E-mail: robert.whitley{at}mail.mcgill.ca
While Bhui/Sashidharan (2003) raise important questions in the debate on whether there should be separate psychiatric services for ethnic minorities in the UK, a cross-national comparative perspective can shed light on alternative models, which could valuably inform British debate (Kirmayer & Minas, 2000). For example, a substantial research literature has arisen in Australia regarding the importance of providing services to minorities in their own languages (e.g. Ziguras et al, 2003). Similarly, in the USA there is an important literature on the effectiveness of services that ethnically match service users and professionals (e.g. Rosenheck et al, 1995). These issues may be fundamental in any encounter between providers and users and deserve the appropriate attention.
The cultural consultation model developed in Canada (Kirmayer et al, 2003) attempts to take into account culturespecific factors to improve diagnostic assessment, treatment planning and case management. The enormous diversity of Canadian society is not captured by the broad ethno-racial categories commonly used in the UK and USA; thus, specialised clinics for each minority group are not feasible. The consultation model does not assume that any clinician can be a fount of all wisdom, intimately knowing all ethnic, cultural and linguistic groups. The consultation draws on a bank of translators, culture-brokers, anthropologists, religious informants, traditional healers and mental health professionals who can be appropriately assembled to help referring clinicians with assessment and treatment. The aim is to improve the quality of care at all levels of the health care system rather than segregate ethnic-groups. Every consultation is an opportunity for in-service training of referring clinicians, with an emphasis on transfer of knowledge. This increases their cultural competence and facilitates collaborative work with culturespecific resources in both the health care system and the community.
Bhui rightly notes that this model, like any other service, will fail without sustained funding. There are also medico-legal issues related to the use of culture-brokers that must be addressed before implementation. However, the model provides an important resource that can promote the appropriate diagnosis and treatment of service-users, while gradually enhancing cultural awareness throughout the health care system.
REFERENCES
Bhui, K./Sashidharan, S. P. (2003) Should there
be separate psychiatric services for ethnic minority groups (debate)?
British Journal of Psychiatry,
182, 10-12.
Kirmayer, L. J. & Minas, H. (2000) The future of cultural psychiatry: an international perspective. Canadian Journal of Psychiatry, 45, 438 -446.[Medline]
Kirmayer, L., Groleau, D., Guzder, J., et al (2003) Cultural consultation: a model of mental health service for multicultural societies. Canadian Journal of Psychiatry, 48, 145 -153.[Medline]
Rosenheck, R., Fontana, A. & Cottrol, C. (1995) Effects of clinicianveteran racial pairing in treatment of posttraumatic stress disorder. American Journal of Psychiatry, 152, 555 -563.[Abstract]
Ziguras, S., Klimidis, S., Lewis, J., et al
(2003) Ethnic matching of clients and clinicians and use of
mental health services by ethnic minority clients. Psychiatric
Services, 54, 535
-541.
Barts & The London School of Medicine, Queen Mary, London EI 4NS, UK
The debate on specialist services for Black and minority groups is a most welcome opportunity to compare and contrast international models of culturally capable services. Whitley, Kirmayer & Jarvis echo the proposal by Waheed et al (2003) that the consultation model established in Canada is to be commended, irrespective of the context in which service models are located. The Canadian approach to diversity in society and in mental health services appears to be more welcoming and supportive in terms of financial investment; furthermore, such an approach endorses the view that specialist rather than separate provision can be useful and is necessary to meet the needs of ethnic minority citizens.
The issue in the UK is that separate funding for special services is rarely available and, as outlined in the original debate (Bhui/Sashidharan, 2003), is ideologically opposed by providers in favour of an integrationist solution. However, this strategy has failed to ensure that generic mental health services are culturally capable or appropriate. Two recent policy documents launched by the Department of Health (2003a,b) attack this issue from quite distinct perspectives, but neither promotes specialist service provision or the consultation model, which, in the UK at least, has often been championed by charismatic and highly motivated clinicians, without the support of sustained investment or a spread of learning throughout the workforce. The first of these policy documents (Inside Outside; Department of Health, 2003a) recommended a cultural capability framework in which a consultation model may have been usefully located but, to date, there is no implementation plan. In some ways these issues are not dissimilar to debates about models of assertive outreach or early intervention, and whether such services are similarly valuable in different cultural and service contexts, irrespective of the transferability of the model. By default, specialist services are being provided in the voluntary sector in the UK; perhaps the consultation model can be commended to policy makers and service providers in the UK as an approach worthy of investment and evaluation. This will need commitment to improve clinical practice skills, and a reorganisation of services, including specialist provision where appropriate.
REFERENCES
Bhui, K./Sashidharan, S. P. (2003) Should there
be separate psychiatric services for ethnic minority groups (debate)?
British Journal of Psychiatry,
182, 10-12.
Department of Health (2003a) Inside Outside. Improving Mental Health Services for Black and Minority Ethnic Communities in England. London: Department of Health.
Department of Health (2003b) Delivering Race Equality: A Framework for Action. Mental Health Services Consultation Document. London: Department of Health.
Waheed, W., Hussain, N. & Creed, F. (2003)
Psychiatric services for ethnic minority groups: a third way (letter)?
British Journal of Psychiatry,
183, 562
-563.