“Hopefully in five years we can kiss ourselves goodbye”: Why we still need ethno-specific mental health services

CrossCurrents

By Anne Ptasznik

It all started over dim sum. Psychiatrists Dr. Ted Lo and Dr. Peter Chang met with Raymond Chung, a social worker, and several colleagues to discuss how to better meet the mental health needs of Toronto’s Chinese community. They identified two key issues: the lack of language and cultural competency among hospital and other mental health service staff and underutilization of mainstream services by the Chinese population.

It was at this meal that the foundation was laid for what is now the Hong Fook Mental Health Association, an ethnocultural agency serving Toronto’s East and Southeast Asian communities. But while the importance of providing newcomers with linguistically and culturally appropriate services has generally been accepted, the question remains: How can this best be achieved? The founders of Hong Fook opted for a consultation-liaison model, rather than providing direct service, which would involve providing training and support to hospital staff and educating members of East and Southeast Asian communities to use existing resources. The organization would ultimately serve as a bridge to mainstream mental health services. Chung recalls thinking, “Hopefully in five years we can kiss ourselves goodbye.”

That was more than 25 years ago. Hong Fook, which translates as “health and happiness,” has not gone out of business. In fact, celebrating its silver jubilee last year, the agency has grown from a staff of four to more than 50, working in two locations, one in Toronto’s Chinatown and the other in the suburbs. Last year, Hong Fook worked with more than 600 individuals and families.

But is Hong Fook’s rapid growth really the mark of success? Given the founders’ original vision of ensuring that people from diverse cultures would with time be better integrated into mainstream organizations, Hong Fook’s success suggests continuing barriers to accessing mental health services. The story of why Hong Fook has flourished while integration efforts have floundered is a tribute to the strength of the founders, staff and community volunteers involved with the organization; but it also highlights the changes that need to occur in the mental health system, not only locally, but also nationally, if this country is to meet the needs of its diverse population.

When Hong Fook first started, partnerships were formed with four downtown hospitals, with Hong Fook staff there one day per week. It took some time to inform hospital staff about the facilitative role that these workers could play, but even after their services began to be used, mainstream services never developed the capacity to work independently without the ongoing support of Hong Fook workers, which was the original hope.

Chung, who became Hong Fook’s executive director in 2001, says that for the first 10 years they tried to support people to go to other available services. The frequent complaint, however, was that services had a long enough waiting list without creating services for non-English–speaking clients.

When deinstitutionalization was introduced in the 1980s, community support programs were seen as a necessity. Funds became available to hire case managers, and Hong Fook decided, with much debate, to switch service models. Once it started providing direct service, it was difficult not to continue. For example, the agency started providing its own supportive housing and offered other housing through partnerships. This service grew quickly from three housing units in 2000 to 80 units today. Chung says it would be difficult to transfer the supportive housing program to a provider that does not have the language capabilities or the cultural understanding of Hong Fook staff.

Hong Fook’s growth can be attributed in part to outreach when population numbers indicated a need. In 1984 and 1998, respectively, Hong Fook expanded its services to the Cambodian and Korean communities. Understanding that not all communities see mental health and mental illness from a Western perspective, the agency determines the most culturally appropriate approach. For example, five years ago when a Korean-speaking psychiatrist recommended working with family members because they are major partners in recovery, a meeting was held to provide more information about mental illness. Only two people came out, so Hong Fook took a different tack, including starting a peer leadership program. Now more than 20 family members meet once per month for mutual support.

Success has posed a dilemma. Whenever mainstream organizations have a Chinese-speaking client, their reaction is, “‘There’s Hong Fook, ship them out, it’s their responsibility,’” says Chung. Some consumers and family members tell Chung they don’t want to go to mainstream agencies; they feel comfortable at Hong Fook, where they can see people from their own culture, speak their own language and eat their own food. Chung, who still philosophically supports integration, asks, “So what do we do? Listen to our consumers and communities or look at pushing the system to integrate?”

Chung insists that there could be choice. He is frequently asked how integration can be achieved with so many different ethnocultural communities and limited health care dollars. He recommends using a population health–based approach to see whether the diverse communities are getting their fair share of the resources in particular areas. If not, he recommends redirecting some funding toward that community’s needs and slowly, over time, the inequities would be addressed. “Diversity is not built in one day,” he says, “but we need to take that kind of action.” While this may slightly increase the waiting list for mainstream agencies’ current clients, it would ensure more access for members of marginalized communities.

Lo agrees that there needs to be better planning, starting with a national mental health strategy. He was recently invited to participate on the Canadian Mental Health Commission’s Service Systems Committee and hopes that ultimately there may be some change stemming from those discussions. Lo says that while Toronto is behind in serving the needs of its 180 language groups, Canada is one of many countries worldwide grappling with this issue.

Lo says there also needs to be planning both by provincial health ministries and the planning and funding bodies, which varies from province to province. In Ontario, the new Local Health Integration Networks (LHINs) present opportunities for more integrated planning but they also introduce challenges, as in Toronto alone there are five LHINs to work with to address this issue.

Lo spent two years working with the Toronto–Peel Mental Health Reform Implementation Task Force, co-chairing a committee that recommended setting up a system responsiveness office within the proposed mental health organizing body. While he believes “watchdog” was too strong a word, he saw this office as having the potential to ensure accessibility to cultural and other marginalized groups. But this report was shelved and the recommendations never implemented. Without planning, these groups do not have lobbying power and become one of many vying for services.

When the Hong Fook founders submitted their proposal for the agency, funders asked, “If we give you Chinese and Vietnamese funding, what about the 56 groups that are lined up at our door tomorrow that will ask for money?” And yet, other than Across Boundaries, an ethnocultural mental health service that takes an anti-racist approach, Toronto has, after 25 years, no other ethnocultural-specific mental health services. While not every community has the leadership, resources and size of population to develop its own resources, Lo believes that those who do should be given support to develop these much-needed services.

Lo also sees changes needed at the organizational level. Staff do not only need to reflect the populations served, which some organizations have made some headway in doing; organizations need to ask, “Does it filter down to how the institution is relating to the other community?” For example, is there signage in other languages and are programs addressing a concrete need?

Lo has not given up on cultural consultation as a way to help treatment teams consider cultural factors and resources in addressing the needs of multiple groups. He says this goes beyond language, although he does encourage the use of cultural interpreters. While some organizations bring in interpreters for psychiatric assessments, they need to think more broadly from a cultural perspective. For example, if a client is new to Canada and does not know the city, is a staff member sent out with her on a pass to buy clothes or food?

Finally, there needs to be a long-term strategy for training and development in school curricula rather than just having a few elective courses in diversity. Lo and some of his colleagues are currently working with psychiatry residents to provide this knowledge throughout their training.

As for the future, ensuring that mental health services become more accessible for diverse newcomers remains a priority for Hong Fook. It would like to share its experience and knowledge more with members of other ethnocultural groups. The agency has also begun to educate settlement workers about mental illness in the hopes that there can be earlier intervention. Another focus is broadening the concept of mental health and wellness. Lo says that diverse cultural groups can bring ideas and practices from all over the world that can enrich the mental health system.

Whether the mental health system will implement the changes necessary to become more accessible to diverse ethnocultural communities over the next 25 years remains to be seen, but it is likely that Hong Fook will be there, leading the way.

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