Reprinted from the "Immigrants and Refugees" issue of Visions Journal, 2010, 6 (3), p. 5
Over the past decade we have seen many positive changes to mental health service delivery, which are to be commended. These changes at first focused on adults, but later included the development of mental health services for families, youth and children.
Cultural diversity, however, is a fact of Canadian society. There is still a distinct lack of progress in mental health services for our ethnocultural minority elders. The most recent figures from Statistics Canada show that, over the next 10 years, the percentage of Canadians over the age of 65 with a non-English or non-French-speaking background will increase from 17% to 20%.1 That translates into an increase of about 1 million to 1.3 million people. These are huge numbers—and are just the tip of the iceberg. We therefore need to reflect on our current geriatric mental health programs.
What it means to be an ethnocultural minority elder
Some of our ethnocultural minority elders arrive in Canada as immigrants and refugees during the family unification process: the adults come first, then children and finally the elders. A large majority of these elders will live with their families upon arrival. It’s not rare to see three generations living together under one roof at the beginning of the settlement process.
The majority of ethnocultural minority elders, however, will have arrived in Canada as young or middle-aged adults and will have spent several decades living and working here. Yet they still face many challenges throughout their lifetimes because cultural adaptation is an ongoing process. They may retain the cultural norms and values from their country of origin, where life experience and wisdom would have been generally respected, while younger family members adopt the norms and values of the adopted country. This results in a reduced status within families, neighbourhoods and communities. This loss of status means that the elders’ retirement may differ radically from what they expected. They may find they don’t receive respect and admiration in their new country or even in their own families.
In this sense, ethnocultural elders face a form of “jeopardy.” In other words, they experience a series of personal, family and society challenges that influence mental health. These include personal devaluation, discrimination, alteration in family roles and socio-economic dependence.2-3 Clearly, ethnocultural elders face significant challenges with respect to their mental health.
This is reflected in some of the recent statistics on global mental health and depression in ethnocultural minority elders. For example, older Chinese-Canadians report poorer overall mental health compared to older Canadian adults, and mild-to-moderate depressive symptoms are more common in South Asian older adults compared to older Canadian adults in general.4
Do our ethnocultural elders receive appropriate service?
The answer is clearly no. We have well-developed mental health services throughout British Columbia, but our ethnocultural elders still face major barriers to accessing appropriate services.
What do I mean by appropriate services? I mean culturally responsible services—services that meet the needs and interests of ethnocultural minority elders and that show respect for cultural diversity. Generally speaking, mental health services and policies do not reflect Canada’s diverse demographics, let alone generational differences.
What does this lack of culturally responsible services mean? An initial assessment is often difficult to get as most mental health services are focused on youth and adults. Moreover, various forms of therapy, such as groups, self-help programs and cognitive-behavioural programs, are practically non-existent for ethnocultural minority elders. Similarly, due to the focus on adult and youth, they may not have access to appropriate counselling programs in their communities unless they access them privately. This leaves only the medication approach provided by either family doctors or psychiatrists.
Ability to speak English is still needed to access and understand mental health services and treatment options.5 This language barrier to services is an obstacle that was discussed at the national level more than 20 years ago.6 Individual hospitals and care facilities vary in the quality of their language and interpretation services, ranging from untrained to professionally trained translators.6 And, interpreter services are commonly underutilized by mental health care providers due to the perception that they are expensive and/or difficult to implement.
What can be done?
First, it’s nonsense that interpreter services are difficult to implement. Over 10 years ago here in BC, Fraser Health and Vancouver Coastal Health developed and implemented cost-effective interpreter and translation services together with the Provincial Health Services Authority. This language assistance is provided across all medical services.7
Services offered directly in languages other than English are still uncommon around the province. As a result of the increased number of ethnocultural elders in the Lower Mainland, however, there are now several mental health services provided in other languages. The Cross Cultural Clinic at Vancouver General Hospital provides outpatient services, including psychiatric assessment and psychoeducation, in 13 languages and dialects. There is a cross-cultural mental health liaison program that provides services to members of five target communities: South Asians, Chinese, Latin Americans, Vietnamese and First Nations. Additionally, each mental health team provides services, individually or in group settings, in specific languages. However, outside of the Lower Mainland no such services exist and in their place non-profit immigrant services groups, provide limited support with respect to mental health needs. As a result, most ethnocultural elders outside the Lower Mainland must use mainstream medical services.
Other examples of culturally responsible services in the Lower Mainland can be found in the care home sector. One changed the menu to include ethnic food. Another had introduced culturally appropriate spiritual services. These kinds of small, positive changes can contribute to the mental well-being of elder clients.
Finally, policies must guide appropriate hiring practices with respect to our ethnocultural minority elders. Recruitment should target individuals from ethnocultural groups that reflect our ethnocultural elder population. In addition, a strong leadership component emphasizing culturally responsible care needs to be integrated into clinical and administrative training. This will lay a strong foundation for identifying agents of change and developing cultural responsibility mental health services in the future.
About the authorSoma is Clinical Professor of Psychiatry and Director of the Cross Cultural Psychiatry Program, University of British Columbia (UBC), and Medical Director, Department of Psychiatry, Vancouver General Hospital and UBC Hospital. He is also Medical Director of Adult Mental Health Services, Vancouver Community Mental Health Services, and Physician Leader at Riverview Hospital
Statistics Canada. (2008). Proportion of the population aged 0 to 14 years, 15 to 64 years and 65 years and over in Canada, 1956 to 2056 [Graph]. www.statcan.gc.ca/pub/91-003-x/2007001/figures/4129871-eng.htm.
Dowd, J.J. & Bengston, V.L. (1978). Aging in minority populations: An examination of the double jeopardy hypothesis. Journal of Gerontology, 33(3), 427-436.
Norman, A. (1985). Triple jeopardy: Growing old in a second homeland. London: Centre for Policy on Aging.
Lai, D.W. (2000). Prevalence of depression among elderly Chinese in Canada. Canadian Journal of Public Health, 91(1), 64-66.
Ahmad, F., Shik, A., Vanza, R. et al. (2004). Voices of South Asian women: Immigration and mental health. Women & Health, 40(4), 113-130.
Canadian Task Force on Mental Health Issues Affecting Immigrants and Refugees. (1988). After the door has been opened: Mental health issues affecting immigrants and refugees in Canada. Ottawa: Minister of Supply and Services Canada.
British Columbia. Provincial Health Services Authority. Interpreting services. www.phsa.ca/AgenciesAndServices/Services/Provincial-Language-Service/InterpretingServices/default.htm.