Introduction = en cours de traduction

 

Because the situations are so… so complex. When I listen to a situation, I tell myself, “How are we going to get out of this? Is this family okay? Is there a solution?” But in the end, I find that with the discussions, the suggestions, and so on, there is still a glimmer of hope. And we’re here to plant those seeds of hope in families. And then I think, « Okay, if we were able to find solutions for that family, then that means it’s real, it’s possible. » So, that’s one of the things I find interesting about Transcultural Seminars. I need to know that I can offer hope [to families from cultural minorities], that I can create hope in a family. Because I tell myself that I’m there as an ally for change with the person. We’re going to work together to change things. If I lose that side of me as a practitioner, I tell myself that maybe my place is no longer there. I come to nourish myself in Transcultural Seminars. It allows me to be able to continue in my profession.

 

In our contemporary world of globalized population movements and local demographic changes, encounters between people with diverse cultural backgrounds are becoming more and more frequent. In the field of mental health care, thanks to a plethora of studies conducted over the last decades in transcultural psychiatry and medical anthropology, it is now acknowledged that culture does matter in clinical encounters and plays a major role in mental health problems’ manifestations and care (e.g., Bibeau, 1997; Good, 1993; Jenkins et al., 2004; Kirmayer et al., 2014; Kleinman, 2008). However, despite the role of culture in mental health services being offically recognized (American Psychiatric Association, 2013), actually taking culture into account remains a challenge for many practitioners, even for those who are committed to doing so and who are aware of the complexities that may arise.

This doctoral thesis reflects on such complexities and on the challenges that emerge when teaching mental health and psychosocial practitioners how to integrate and account for culture in their professional interventions. Several elements contribute to this complexity, the first, being that culture is a processes-based, ubiquitous, multidimensional, dynamic, evolving, and often contested phenomenon. Secondly, the fact that cultural processes are in permanent interaction with other social forces makes it impossible to consider culture as an isolated or static “factor” or “variable”. Finally, the very definition of culture is an elusive one. Not only is the concept being ceaselessly reworked and questioned theoretically, but its very analytical usefulness is constantly being debated in anthropology; notably, due to its association with the colonial enterprise. Bearing this in mind, the posture adopted in this thesis is that teaching professionals to consider culture in their interventions is preferable to not doing so, as long as this education is conducted in a way that avoids an essentialist perspective, which further stereotypes, stigmatizes, and harms cultural minorities. This thesis will thus explore the challenges inherent to such educational initiatives, and how thinking through these issues and considering their practical implications may help avoid the above-mentioned pitfalls. These considerations will be reflected upon by looking at a specific training model, known as the Transcultural Interdisciplinary and Interinstitutional Case Discussion Seminars, as they unfold in practice in Montréal, Québec, Canada. I will argue that the approach advocated in Montréal’s Transcultural Seminars, and more broadly the decolonial approach to youth mental health care inspired by contemporary critical anthropology, proposes another way of understanding and assisting. Another way of caring. Another way of looking.

Attending to Culture in Professional Mental Health Practices

Understanding the influence of culture on the experience, expression, and treatment of psychopathology is a long-standing concern in the mental health disciplines. This interest has its historical roots in the colonial period and has grown out of the encounter between Euro-American psychiatrists and “other” populations. The initial approach to such considerations for culture was largely based on a colonial and exoticizing view; however, the field of transcultural psychiatry has continuously evolved, with its efforts aimed at responding to the mental health needs of culturally diverse populations without this “othering” perspective (Anderson et al., 2011; DelVecchio Good et al., 2011). More recently, with the end of colonization and the acceleration of globalization, the focus has shifted from studying “the culture of the patient” to studying the cultural dimension of psychiatric practices and their theoretical foundations through a renewed dialogue between psychiatry and anthropology (Kirmayer & Minas, 2000). This was made possible by the influence of a group of thinkers, notably in North America by members of the Harvard school in the United States who, since the 1970s, have developed a large body of literature around the cultural meaning and subjective experiences of mental health problems and services (e.g., Good & DelVecchio Good, 1981; Kleinman, 1980), as well as by a network of scholars and clinicians in Montréal who were devoted to the study of culture and mental health. Indeed, around the mid-1960s, the city of Montréal was considered as “the center of cultural psychiatry” (Bibeau, 2002). A few years earlier, in 1955, the section of Transcultural Psychiatric Studies was created at McGill University by Eric Wittkower and Jack Fried. Over the years, members of what became the Division of Social and Transcultural Psychiatry in the early 1980s conducted studies on the cultural variations of psychiatric disorders, healing practices, and attitudes towards mental illnesses (Prince, 2000). Thanks to the contributions of the above-mentioned thinkers, it is now acknowledged that culture matters in the clinical space, as evidenced by the inclusion of the Cultural Formulation Interview (CFI) in the American Psychiatric Association (APA)’s DSM-5 (2013). The CFI is an interview tool that was developed as a way to further operationalize the work initiated in DSM IV’s “Outline for Cultural Formulation” (APA, 1994) regarding the collection of cultural elements in the context of patient assessment and their integration in treatment plan elaboration (Lewis-Fernandez et al., 2015).

Nowadays, McGill’s Division of Social and Transcultural Psychiatry is under the scientific direction of Laurence J. Kirmayer and includes a network of scholars and clinicians who continue to carry out research, and clinical and training activities on culture and mental health. In Montréal and Québec, the contribution of the Groupe interuniversitaire de recherche en anthropologie médicale et en ethnopsychiatrie (GIRAME) has also been significant. This network, which was founded in 1974 by Guy Dubreuil and H. B. M. Murphy, operated during several years under the leadership of anthropologist Gilles Bibeau. The overall objective of the GIRAME was to study and disseminate research results on the interface between health, illness, and sociocultural elements (Bibeau, 2002). Currently, the SHERPA University Institute, led by Scientific Director Jill Hanley, is dedicated to the development, evaluation, and dissemination of primary care interventions and prevention practices adapted to multiethnic contexts. SHERPA is located in a community health and social services center (CLSC) in Parc-Extension, one of the most culturally diverse neighbourhoods in Montréal. SHERPA also works in collaboration with the Research and Action on Social Polarizations team (RAPS), under the scientific direction of Cécile Rousseau, to address the growing polarization of societies – including Québec’s – around identity and inter-community issues. This phenomenon has a definite impact on the mental health of both cultural minorities and majorities, as well as on current prevention, training, and intervention initiatives, such as the one examined in this thesis.

Cultural Competence, Cultural Safety, and Anthropological Critiques

Practitioners and health systems commonly refer to cultural competence when considering the importance of culture on mental health concerns and care. Overall, the goal of cultural competence is to develop “the capacity of practitioners and health services to respond appropriately and effectively to patients’ cultural backgrounds, identities and concerns” (Kirmayer, 2012). It is commonly held that this requires addressing both knowledge (savoirs) and practices (savoir-faire), as well as attitudes (savoir-être) towards cultural differences (Sue, Arredondo, & McDavis, 1992). It may also involve the development of both generic and specific competencies to address a range of practical issues in intercultural work (Fung & Lo, 2017; Lo & Fung, 2003). Specific cultural knowledge and strategies are particularly meaningful if care is provided in settings with easily identifiable ethnocultural groups, such as Indigenous communities (Wendt & Gone, 2012), but less so in environments that have been labelled as culturally “shattered” or “hyperdiversified” (DelVecchio Good & Hannah, 2015). In Québec, interestingly, the term intercultural competence is preferred to that of cultural competence, both in the literature and in practice, as the use of the inter prefix has the advantage of underlining the dynamic aspect of interpersonal encounters, and the fact that they take place at the confluence of multiple cultural worlds.

Criticisms of cultural competence have warned against a simplification of anthropological fundamentals, notably a lack of understanding and confusion of the concepts of culture, ethnicity, and race. Questionable elements of certain cultural competence models include a misunderstanding of culture as a static entity, treating culture as a variable, emphasizing cultural differences to the detriment of structural power imbalances, overlooking intra-group diversity, and not recognizing biomedicine as a cultural system itself (Carpenter-Song et al., 2007). Thus, a major challenge remains of finding the right balance between two extremes when it comes to training and developing the cultural competence of practitioners. On the one hand, “cookbook” approaches are based on culturalism and may further stereotype, stigmatize, and harm cultural minorities, while on the other hand, individual-centered approaches may be read as “cultural avoidance” in the sense that “one size does not fit all” (Alegria et al., 2010).

To avoid such oversimplifications of culture or its complete disregard, other approaches such as cultural humility and cultural safety have been proposed to complement cultural competence. Cultural humility emphasizes the importance of a reflexive and humble posture in intercultural care (Tervalon & Murray-Garcia, 1998), while cultural safety tends to address issues of power and discrimination in health service delivery (Anderson et al., 2003; Papps & Ramsden, 1996; Ramsden, 1992). The cultural safety approach will be further presented in the first chaper of the thesis, but I would like to add a side note on its application in the local context of the present study, that is in French-speaking Québec. About thirty years ago, the notion of cultural safety (kawa whakaruruhau in Māori) was developed in New Zealand (Aotearoa) to account for the hurtful experiences of Māori people in the health care system. Originally, the intention was to challenge culturalism and unveil systemic racism in health services by addressing the issue of coloniality and power relations in the clinical encounter (Papps & Ramsden, 1996). Over time, the cultural safety approach has been reworked and applied to other discriminatory situations, with LGBTQ communities for instance, while in Canada it is still mainly associated with the health care provided to Indigenous Peoples. In Québec, this approach is increasingly popular, but it is difficult to find an equivalent in French to the expression “cultural safety”. In general, only the word sécurité is used to translate both the word “safety” and the word “security”, although these two English terms do not have quite the same semantic scope. Thus, the expression that was chosen by the actors involved in the fight against inequalities in the health system is that of approche par sécurisation culturelle (Blais, 2020), which roughly translates back to “approach by cultural securing”. Although at first glance anecdotal, this linguistic shift nevertheless reveals once again a fundamental misunderstanding of the concept of culture as understood in contemporary anthropology. While the word “securing” can indeed be defined by the action of reassuring and building trust, it can also refer to the action of stabilizing a situation or protecting a place in the face of a potential danger, such as erecting a barricade. Yet, all the richness of cultural worlds lies specifically in the idea that they are open, heterogeneous, fluid, and never fixed systems. Moreover, far from always representing a danger, intercultural encounters can on the contrary be sources of great learning and creative processes. Unfortunately, this expression is now enshrined in the literature and in practice, and since words have an affective range that influences us deeply and often unconsciously, the use of this vocabulary may have the unfortunate effect of increasing confusion as to the dynamics of culture in the clinic, or even hinder the intercultural dialogue from which an allyship towards a decolonization of practices could emerge.

Finally, it is important to stress that to reduce disparities and inequities in the health status and care of cultural minorities, there is a need to improve both the cultural competence and “structural competence” (Metzl & Hansen, 2014) of professionals and of health systems. Underlying processes that lead to such disparities need to be thought of and addressed globally, from the intimacy of the clinical encounter to the systemic and political levels. As such, intercultural training initiatives can only be successful if they are accompanied with other actions at the institutional level. These can include better accessibility to interpreters, increased consultation time, intercultural training of non-clinical or administrative personnel, partnership with ethnocultural community-based organizations, and increased cultural diversity among staff (Pouliot et al., 2015). Inequities in the health status and care of cultural minorities also highlight the fact that taking into account cultural elements in mental health services raises complex ethical and political issues relating to the use and distribution of collective resources, which are further framed by local representations of alterity (Johnson-Lafleur, 2016). That being said, this will not be the main focus of the present thesis which will instead dive into the intricacies of a specific group-based training modality and explore the trainees’ perspective and experience with it.

Practitioners’ Experiences and Perspectives in Intercultural Training

In youth mental health care, the clinical assessment of a presenting situation is influenced by different elements, many of which are of a cultural nature; notably, the family members’ and practitioners’ potentially diverging views on the problem at hand and the course of action that should be taken (Kirmayer et al., 2008). Although such elements seem easy to integrate when considered from the comfort of a theoretical distance, when in the field and during intimate clinical encounters, professionals are sometimes confronted with complex situations that require adjustments to their tools, protocols, and “practice as usual” interventions. Indeed, results from a study conducted in the Québec health and social services network indicated that cultural differences are often put forward by practitioners to explain clinical difficulties and impasses (Pouliot et al., 2015). Cultural misunderstandings have also been reported to cause feelings of powerlessness and frustration in practitioners, sometimes even unconscious ones (Daxhelet et al., 2018), which may provoke defensive reactions and adversely affect the quality of their work. Thus, to close the gap between what is advocated in the literature in transcultural psychiatry and the reality encountered in day-to-day practice, the training of professionals is often presented as a solution. However, more often than not this solution is offered without necessarily unpacking what such initiatives would entail and require. It has been argued that intercultural training cannot solely rely on content-focused curriculum, as the training requires practitioners to reflect on their cultural identities and social positionings, as well as to become more aware of their internalized cultural assumptions (Kirmayer et al., 2020). Training guidelines also highlight the importance of hands-on clinical experience under the supervision of clinicians trained in intercultural care (American Psychiatric Association, 2013); however, the availability of supervisors with the capacity to provide such support is rather limited, particularly in youth mental health care and outside major urban centers (Rousseau & Guzder, 2015). To overcome this challenge, group approaches have also been proposed.

The object of this thesis is one such initiative known in the literature as Transcultural Interdisciplinary and Interinstitutional Case Discussion Seminars (De Plaen et al., 2005; Rousseau et al., 2005; Rousseau et al., 2018), although the professionals who take part in it use the simplified expression “Transcultural Seminars” to refer to these meetings. Since the late 1990s, this training modality has been gradually developed at the request of primary care practitioners who worked in Montréal neighborhoods with a high degree of ethnic diversity. Initially, they were only attended by practitioners working in community health and social services centers (known in Québec as “CLSCs”) who wanted to improve their intercultural competency, but nowadays, the Transcultural Seminars also welcome child and youth protection employees (commonly called “youth centers”), and professionals from the school milieu. These monthly, three-hour meetings bring together about twenty practitioners to discuss a complex clinical case in depth. A case that is said to involve “cultural” or “intercultural” issues is brought to the group by a participant or a team for discussion, including misunderstandings between families and caregivers, therapeutic impasses attributed to cultural elements, difficulties of collaboration, and so on. Thus, the training is based on real-life experiences, and the discussions are imbued with the emotions and cognitions of the practitioners who present a situation, as well as by the reactions of those who receive the stories and assist their colleagues to expand their understanding of the case and develop an intervention plan. These meetings are conducted under the supervision of one or two clinicians with extensive work experience in intercultural contexts. The Montréal’s Transcultural Seminar model will be further described and explored in each of the articles that make up the thesis.

Methodology and Research Objectives

The intention of this doctoral thesis is to report on the analysis of Montréal’s Interdisciplinary and Interinstitutional Case Discussion Seminars or “Transcultural Seminars”, a training modality for practitioners involved in the field of youth mental health to support them in their intercultural work. The general objective of the study was to better understand this professional practice by observing it unfold across different contexts and reflecting on its conditions of possibility and its various effects. The research’s aim was to examine the processes taking place in Seminars and their transformative effects. To do so, a qualitative methodology was selected, as it allowed for an exploration of these impacts and processes, both in terms of group dynamics and of the participants’ lived experience, and in terms of their manifestations in discourse and in non-verbal performances.

The epistemological perspective that was taken for this study was an interpretive constructivist approach – which posits reality as multiple, and meaning as constructed (Ponterotto, 2005) –, the most suitable paradigm to study the lived experience of research participants. Additionally, since this thesis also seeks to “disrupt and challenge the status quo” (Kincheloe & McLaren, 2011, p.285), a critical stance was adopted in an effort to consider the importance of the researcher’s role and of power relations in the scientific enterprise and in the production of knowledge (Creswell, 2003). Overall, the research posture that was adopted during this project was characterized by an attitude of openness, listening and decentering, and reflexivity, rather than being based on the idea of creating “expert” knowledge; thus, resulting in knowledge that was co-created as a result of encounters. My scientific approach is based on a vision of human beings as being both the objects of study and remaining thinking, acting, and feeling beings with a legitimate perspective on their own reality. In this respect, to combine the strengths of the emic and etic perspectives, the writings produced for this thesis have been reviewed by both people involved in the professional practice and who are the object of this study, and by external reviewers who are less – if not at all – familiar with its content (Creswell & Miller, 2000).

In terms of methodology, it is important to note that this doctoral project, which began in the fall of 2015, is a continuation of a previous evaluation research conducted between 2012 and 2015 on the impact of Transcultural Interdisciplinary and Interinstitutional Case Discussion Seminars. This previous study was directed by Cécile Rousseau, my PhD supervisor, and for which I was in charge of coordinating the research activities. As such, the first two papers in the thesis are based on analyses that included data from the research program “Collaborative Care in Youth Mental Health”, a program that was co-directed by Cécile Rousseau and Lucie Nadeau (2012-2018), and that included the aforementioned research on Transcultural Seminars. Although this evaluative study documented the positive contributions of the Seminars in terms of improving the intercultural responsiveness and general clinical competence of practitioners (Rousseau et al., 2018), one of its limitations was the reduced access to the lived experiences of Seminar participants, as the data collection was conducted through observations and group interviews. Thus, to gain a deeper understanding of the processes unfolding during Transcultural Seminars and to take a more intimate look at the experiences of the people involved in the meetings, an ethnography of Seminars was pursued until the spring of 2018 and turned into a doctoral project.

During the period of the doctoral fieldwork per se (2015-2018), four different groups of Transcultural Seminars, located in four Montréal neighbourhoods, met once a month during the academic year, that is from September to May with a break during the summer period. Of these groups, three of them obtained official authorization from their institution (locally called a “certificate of convenience”) to participate in the present study, allowing for the possibility of their members to take part in research activities. A multi-centric certificate of approval from the Research Ethics Board was obtained from Le CIUSSS du Centre-Ouest-de-l’Île-de-Montréal for conducting the study.

As a whole, the writings produced for this doctoral project reflect on a five-year period of ethnographic fieldwork that consisted of taking part in the meetings of the Transcultural Seminars and discussing them with the people involved. This thesis is divided into four chapters, with each chapter presenting a scientific paper that addresses a different aspect of the practice. Since each paper is intended to be a stand-alone product, these articles all contain specific research questions and an account of the methods used, as well as the literature providing a backdrop for the analyses. The theoretical frameworks that informed the analyses included the cultural safety paradigm, insights from game theory, the community of practice paradigm, and a politico-psychoanalytical perspective on representations and images. This literature will not be reproduced here, in order to avoid redundancy and to make the thesis less weighty. However, to provide an overall picture of research activities, the different data sources and research questions for each article are presented in the Appendix (see Appendix A).

With hindsight, I realize that this thesis takes the form of a montage of theoretical perspectives in order to better understand a complex phenomenon – Transcultural Seminars – by observing it from different angles, with different conceptual tools. In this sense, one can say that the complexity of the object of study and its multiple layers of processes and meanings call for a multiplicity of analytical lenses. This is why I like to say that this manuscript-based thesis uses the power of “montage” (Suhr & Willerslev, 2013), in that each article presents a different perspective on the complex reality of intercultural training as it unfolds during Transcultural Seminars, with the combination of these perspectives providing an overall better understanding of the phenomenon, while leaving a part of the “unknown” and “invisible” existing between the cracks. In this respect, the writing style used in certain parts of the thesis – in particular the fourth chapter – can be unsettling for some readers who are more accustomed to a “scientific”, “factual” or “detached” tone in which the author and their creative work hides behind the use of the third person. This methodological choice was intended to make the reader experience the destabilizing effect of changing language and genre to look at situations of suffering and their professional care. This is the same feeling that people who are not used to Transcultural Seminars may experience when they first participate, as they are asked to move from “chart talk” – a clinical language that enumerates a list of symptoms and procedures – to a more storytelling approach that uses language to narrate events and emotions, including those that affect them closely (Mattingly, 1998). In this sense, I hope the form of the thesis echoes well the object of its content.