Color Coded Cognitive Care by CRRF-FCRR

CANADIAN RACE RELATIONS FOUNDATION

COLOR CODED COGNITIVE CARE: IMPROVING MENTAL HEALTH CARE FOR ETHNORACIALIZED INDIVIDUALS IN ONTARIO Simran Dosanjh University of Toronto October 2020

Color Coded Cognitive Care: Improving Mental Health Care for Ethno-Racialized Individuals in Ontario Ethno-racialized individuals suffering from mental illness face a number of barriers to appropriate treatment under the existing mental health care system in Ontario. Compared to the general population, ethno-racialized individuals have higher rates of involuntary admission and misdiagnosis, as well as higher rates of noncompliance with treatment plans proposed by psychiatrists.1 One reason accounting for this difference is the inherent biases found both in the practice of psychiatry and in the legal framework that governs mental health in Ontario under the Mental Health Act (MHA).2 This paper will focus on three barriers ethno-racialized individuals face in accessing appropriate mental health care, discussing how these barriers result in unjust legal outcomes. The first barrier is related to cultural factors and experiences with the mental health care system which restrict access to mental health care services.3 Without access to mental health care, ethno- racialized individuals suffering from mental illness are more likely to be involuntarily presented to mental health care facilities.4 Those who are able to access mental health services face a second barrier to treatment; misdiagnosis. Psychiatrists are more likely to misdiagnose ethno- racialized patients by failing to consider their cultural context.5 This can lead to either involuntary treatment when treatment is not justified or a discharge from treatment when treatment is required. Once (in)appropriately diagnosed with a mental disorder, ethno-racial

Ruby Dhand, "Access to Justice for Ethno-Racial Psychiatric Consumer/Survivors in Ontario" (2011) 29 Windsor Y B Access Just 127 at 128 [Dhand “Access”]. 2 Mental Health Act, RSO 1990, c M.7[Mental Health Act]. 3 Yvonne Tieu & Candace A Konnert, "Mental health help-seeking attitudes, utilization, and intentions among older Chinese immigrants in Canada" (2014) 18:2 Aging & Ment Health 140 at 143 [Tieu & Konnert]. 4 Martin Rotenberg et al, "The role of ethnicity in pathways to emergency psychiatric services for clients with psychosis" (2017) 17 BMC Psychiatry 137 at 142 [Rotenberg et al]. 5 Dhand “Access”, supra note 1 at 128.

2 patients confront a third barrier to appropriate health care as they are overwhelmingly denied culturally appropriate treatment plans, resulting in higher rates of noncompliance and coercive treatment.6 Each of these barriers to appropriate mental health care will be discussed in Section 1. Section 2 proposes a series of recommendations for improving the legal and social framework of mental health care for ethno-racialized Ontarians. The paper concludes with a brief summary of the challenges ethno-racialized individuals face in mental health care and the avenues for reform. SECTION 1: BARRIERS TO MENTAL HEALTH CARE Barrier 1: Accessing Care without Cuffs The provisions of the MHA regulating appropriate mental health care are only engaged once an individual seeks mental health care services, or is involuntarily presented to a mental health care facility. Compared to the general population, ethno-racialized individuals are far less likely to voluntarily access mental health care services, increasing the likelihood that they will be involuntarily presented to a mental health care facility.7 Without access to treatment and professional support, ethno-racialized individuals suffering from mental illness are more likely to experience psychotic episodes in public.8 Police officers who witness these episodes may believe the ethno-racialized individual suffers from a mental disorder and that they pose a significant risk of harm, triggering their power under the MHA to involuntarily detain and present the individual to a mental health care facility for assessment.9 This can be a traumatizing and humiliating

Ibid. Rotenberg et al., supra note 4 at 142. 8 Ibid. 9 Ibid. 7

3 experience for ethno-racialized individuals who are more likely to fear and mistrust the police.10 Additionally, involuntary pathways into the mental health care system will likely to lead to further reluctance towards engaging with the mental health care system in the future.11

Unfortunately however, ethno-racialized individuals disproportionately experience involuntary pathways to treatment.12 A study by Martin Rotenberg and his colleagues assessing individuals who were involuntarily presented to emergency departments in Toronto hospitals from 2009-2011 found that East Asians, South Asians and Blacks were more likely to be presented to the emergency department involuntarily when compared to White North Americans.13 The authors suggest that the underutilization of mental health care services by ethno-racialized groups may account for these findings as a lack of treatment can lead to psychotic episodes requiring coercive measures by the police.14 Thus, the need to improve access to mental health care for ethno-racialized individuals is essential to reduce involuntary pathways to care and police involvement.

To improve access to mental health care, the barriers impeding access for ethnoracialized individuals must first be identified. A number of studies suggest that ethno-racialized individuals do not seek professional help for mental illness as a result of the stigma their cultures attach to mental illness.15 Although Western culture also stigmatizes mental illness, other cultures stigmatize mental illness to a greater extent, where individuals suffering from mental 10

Magnus Mfoafo-M'Carthy, "Community treatment orders and the experiences of ethnic minority individuals diagnosed with serious mental illness in the Canadian mental health system" (2014) 13 Int J for Equity in Health 1 at 6 [Mfoafo-M'Carthy]. 11 Rotenberg et al., supra note 4 at 142. 12 Dhand â&#x20AC;&#x153;Accessâ&#x20AC;?, supra note 1 at 129. 13 Rotenberg et al., supra note 4 at 141. 14 Rotenberg et al., supra note 4 at 142. 15 Kwame McKenzie, "Issues and Options for Improving Services for Diverse Populations" (2015)34:4 Canadian J of Community Ment Health 69 at 78 [McKenzie].

4 illness are ostracized from their families and communities as a result of the shame associated with their illness.16 The connection between cultural values and access to mental health services has been noted in a variety of studies. For example, in Yvonne Tieu and Candace Konnertâ&#x20AC;&#x2122;s study of 149 older Chinese Canadians, the authors found that traditional Chinese cultural beliefs were associated with a reluctance to seek professional help for mental health issues.17 Most of the respondents who indicated they would seek help for mental illness were likely to do so by speaking to their family physician or a non-professional, such as a family member or friend, rather than seeking help from a psychiatrist or other mental health care professional.18 Tieu and Konnert suggest that cultural beliefs increase reluctance to seek professional help for mental illness because Chinese culture strongly stigmatizes mental illness.19 According to a Chinese respondent in a study of women facing major depressive disorder, in China, people with mental illness are â&#x20AC;&#x153;stoned and stepped upon.â&#x20AC;?20 To avoid the stigma of mental illness, this respondent suggests that if a family member suffers from mental illness, it is preferable not to disclose this to anyone.21 Thus, it is likely that Chinese individuals would be more reluctant to access mental health services due to cultural beliefs and values. Along with Chinese individuals, a study by Farah Islam and her colleagues found that the adult immigrant population in Ontario had the lowest rate of mental health consultation across all

Lyren Chiu et al, "Spirituality and Treatment Choices by South and East Asian Women with Serious Mental Illness" (2005) 42:4 McGill University 631 at 642 [Chiu et al]. 17 Tieu & Konnert, supra note 3 at 143. 18 Ibid. 19 Tieu & Konnert, supra note 3 at 145. 20 Chiu et al, supra note 16 at 642. 21 Ibid.

5 service provider types, including family physicians and psychiatrists.22 Similar to ChineseCanadians, the authors found that immigrants were most likely to consult family physicians when they did consult a service provider regarding mental illness.23 These findings of the immigrant population more generally also intersect with race; compared to White immigrants, South Asian immigrants were 37% less likely to consult mental health care professionals, while Blacks were 47% less likely and Chinese individuals 71% less likely.24 To explain why ethno-racialized immigrants are less likely than the general population to access mental health services, Islam and her colleagues suggest that the strong stigma certain cultures attach to mental illness discourages racialized immigrants from seeking professional help for mental illness.25 The authors also suggest that financial difficulties and limited transportation means are barriers to accessing mental health services as psychologists and other mental health care professionals who are not covered under OHIP are not as readily accessible or financially feasible for recent immigrants and ethno-racialized groups who suffer disproportionately from poverty.26 This study supports the claim that ethno-racialized individuals are less likely to access mental health care as a result of cultural values and beliefs, as well as financial and mobility constraints. Along with cultural values, previous negative experiences with the mental health care system may also explain why ethno-racialized individuals are less likely to access mental health care services. A number of studies have found that ethno-racialized individuals express disappointment in their interactions with mental health care providers as they feel the providers

Farah Islam et al., "Mental Health Consultation Among Ontario's Immigrant Populations" (2017) Community Ment Health J 1 at 1 [Islam et al.] 23 Islam et al., supra note 21 at 1. 24 Islam et al., supra note 21 at 9. 25 Ibid. 26 Ibid.

6 do not spend enough time with them or truly listen to their concerns.27 The authors of these studies suggest that cultural expectations about the provider-client relationship among certain ethno-racialized groups may cause this disappointment, which increases reluctance to accessing mental health services again.28 For example, in some South Asian cultures, traditional doctors have insight into their patientâ&#x20AC;&#x2122;s family, professional and personal lives as a result of building a relationship with patients over the years they have serviced the local community to which the patient belongs.29 Confronted with a doctor or mental health care provider in Ontario who services hundreds of patients and is focused solely on the patientâ&#x20AC;&#x2122;s illness alone, rather than the patientâ&#x20AC;&#x2122;s personal lives as well, ethno-racialized individuals from cultural backgrounds that encourage dialogue between doctors and patients may find the mental health care provider cold and hasty.30 This negative experience may make it less likely that the ethno-racialized patient will visit the health care facility again. Along with cultural expectations about the service provider-patient relationship, some studies suggest that experiences of racism or disrespectful care make ethno-racialized individuals less likely to access mental health services again.31 One of the case studies discussed by Lauren Mizock and Zlatka Russinova in their study on how culture influences acceptance of mental illness for example, involved an older Black woman who described racism and sexual coercion

Nan Zhang Hampton & Seneca E Sharp, "Shame-Focused Attitudes Toward Mental Health Problems: The Role of Gender and Culture" (2014) 57(3) Rehabilitation Counseling Bulletin at 1897 [Hampton & Sharp]. 28 Ibid. 29 Chiu et al, supra note 16 at 644. 30 Hampton & Sharp, supra note 26 at 1897. 31 Lauren Mizock & Zlatka Russinova, "Racial and Ethnic Cultural Factors in the Process of Acceptance of Mental Illness" (2013) 56:4 Rehabilitation & Counselling Bulletin 229 at 229 [Mizock & Russinova].

7 by male staff when she was hospitalized for her schizophrenia and bipolar disorder.32 These negative and traumatic experiences can foster mistrust towards mental health care facilities and service workers, making it less likely that ethno-racialized individuals will actively seek mental health care when they need it. Along with racism and sexism within mental health institutions, societal discrimination also corresponds with lower rates of mental health care consultation amongst ethno-racialized individuals.33 For example, a study by Charmaine C. Williams and her colleagues assessing the experiences of 704 women and transgender/gender liminal Ontarians with depression found that “everyday discrimination” was the strongest predictor of unmet need.34 “Everyday discrimination” involves discrimination in social and informal contexts.35 The authors suggest that this correlation may be attributed to the fact that individuals who experience discrimination become more distrusting of social institutions, and are less likely to actively seek mental health care from those institutions.36 Thus, discrimination and racism both within and outside of mental health care facilities, as well as culturally informed stigma all help explain why ethno-racialized individuals are less likely to access mental health care. To reduce the disproportionate rate at which ethno-racialized individuals are presented to mental health care facilities involuntarily, these factors influencing accessibility must be addressed.

Mizock & Russinova, supra note 30 at 223. Charmaine C Williams et al, "Depression and discrimination in the lives of women, transgender and gender liminal people in Ontario, Canada" (2017) 25:3 Int Migration & Integration 1139 at 1139 [Williams et al]. 34 Williams et al., supra note 32 at 1147. 35 Williams et al., supra note 32 at 1139. 36 Williams et al., supra note 32 at 1147. 33

8 Barrier 2: Discriminatory Diagnoses Ethno-racialized individuals who overcome accessibility barriers face an additional barrier to appropriate care as they are more likely to be misdiagnosed by mental health practitioners.37 Misdiagnosis can result in ethno-racialized individuals either being discharged from care when treatment is warranted or subject to involuntary treatment when it is not warranted. This is a significant problem as ethno-racialized individuals are either being denied their liberty or they are being denied appropriate care. One reason accounting for misdiagnosis is that psychiatrists fail to consider the individual’s cultural context when assessing whether they are suffering from a mental illness. For example, in determining whether an individual is suffering from depression, psychiatrists evaluate whether that individual is reacting to personal circumstances in “appropriate” ways, assessing behavioural cues such as facial expressions and eye contact.38 What is “appropriate” however, varies in different cultural contexts.39 In some Asian cultures for instance, avoiding eye contact is a sign of respect. Psychiatrists who fail to account for these cultural factors may be more likely to inappropriately diagnose Asian individuals with depression based on their behavioural cues.40 Similar misconceptions can be made when diagnosing an individual with schizophrenia, where psychiatrists must decide whether an individual’s beliefs are true or imaginary.41 In this context, psychiatrists may deem certain religious or spiritual beliefs associated with an individual’s culture as psychotic or paranoid, when they are perfectly normal in the individual’s culture.42

Dhand “Access”, supra note 1 at 128. Suman Fernando, Race and Culture in Psychiatry (London: Routledge, 1988) at 137 [Fernando]. 39 Ibid. 40 Ibid. 41 Fernando, supra note 37 at 140. 42 Ibid. 37 38

9 A variety of studies support the proposition that failing to consider an individual’s cultural background may lead to misdiagnosis. For example, many researchers have found that, in contrast to Western culture where symptoms of mental illness are expressed in terms of cognitive functioning, individuals from East and South Asian cultures express mental health concerns in terms of somatic, or physical, symptoms, such as bodily pain.43 This may be due to the stigma that Asian cultures tend to attach to mental health issues, as well as a dualistic understanding of the mind-body relationship.44 The connection between culture and symptomology is emphasized by Juveria Zaheer and colleagues who assessed the experiences of Chinese women who had depression and suicidal ideation.45 Supporting the findings of previous studies, the participants to this study articulated their experience of depression in terms of somatic symptoms, such as increased blood pressure, insomnia, and bodily pain.46 The women also expressed culturally sanctioned idioms of distress, suggesting that the somatic symptoms they experienced resulted from a depletion of “qi”, or vital energy.47 The authors of this study propose Confucius beliefs, such as the concept of “ren,” or endurance through sustained stress, contributed to their suicidal ideation.48 The findings of this study highlight the importance of considering an individual’s cultural context when screening them for mental illness. Without considering an individual’s cultural context, expressions of somatic symptoms may viewed as indicators of physical illness, rather than mental illness, and

Mizock & Russinova, supra note 30 at 235. Ibid. 45 Juveria Zaheer et al., "I just couldn’t step out of the circle. I was trapped': Patterns of endurance and distress in Chinese-Canadian women with a history of suicidal behaviour" (2016)160 Social Science & Medicine 43 at 43 [Zaheer et al.] 46 Zaheer et al., supra note 44 at 49. 47 Zaheer et al., supra note 44 at 51. 48 Ibid. 44

10 their spiritual beliefs, such as Confucius thought, may be dismissed as irrelevant to their mental health. It is also important to note that while some individuals from Chinese or other Asian backgrounds will express somatic symptoms, others will not verbalize any symptoms as a result of the stigma attached to mental illness. For example, Lyren Chiu and her colleagues’ study found that Chinese and South Asian women in Vancouver were more reluctant to tell a psychiatrist about their concerns of mental illness as a result of cultural stigma.49 This finding suggests that individuals from these backgrounds may require more time with psychiatrists and probing questions before an informed diagnosis can be made. Along with misunderstanding symptomology, ethno-racialized individuals may be misdiagnosed by psychiatrists who fail to consider how cultural factors influence a patient’s understanding and acceptance of mental illness. For example, in Lauren Mizock and Zlatka Russinova’s study on the role of culture in accepting mental illness, one participant understood his illness as “ataque de nervios,” a culture-bound syndrome prevalent in many Latino cultures that involves unexplained anger as a result of stress.50 Without considering this individual’s cultural context and the way he understands his own mental condition, a psychiatrist may have misinterpreted his anger as indicative of another illness, leading to misdiagnosis. Another participant in this study understood his mental illness in terms of the Buddhist notion of karma.51 As a Japanese American, this participant indicated that he experienced somatic symptoms which he could only make sense of through meditation and Buddhist belief.52 Without considering the cultural context of this participant, a psychiatrist may have interpreted

Chiu et al, supra note 16 at 642. Mizock & Russinova, supra note 30 at 224-235. 51 Mizock & Russinova, supra note 30 at 236. 52 Mizock & Russinova, supra note 30 at 235. 50

11 his somatic symptoms as a sign of physical illness, or may have attributed his understanding of karma to mental illness. In contrast to the case studies discussed above, where the patient’s understanding of their mental illness was influenced by cultural factors, some cultures do not understand mental illness as an illness at all. For example, as described by Ruby Dhand, some cultures, such as Somali culture, do not understand mental health concerns as an ‘illness’ but rather, they view it as a “gift from God.”53 Ethno-racialized patients who express such views may be inappropriately diagnosed as psychotic and potentially incompetent for refusing to accept their ‘illness.’ This may in turn lead to involuntary treatment, despite the fact that the ethno-racialized individual is fully competent and simply understands their mental state in a way that is normal for their culture. Thus, ethno-racialized individuals are likely to be misdiagnosed by psychiatrists who fail to consider how culture influences an individual’s understanding of their mental health condition as well as their symptomology. Misdiagnosis can lead to involuntary treatment and a denial of liberty, or discharge and a denial of care, presenting a barrier to appropriate mental health treatment. Barrier 3: Treatment Tunnel-Vision and the Prioritization of Western Medicine Once (in)appropriately diagnosed, a third barrier ethno-racialized individuals face in accessing appropriate mental health care is that they are often denied culturally appropriate treatment options.54 Compared to the dominant group, ethno-racialized individuals with mental illness have higher rates of non-compliance with mental health care treatment plans, as well as

Dhand “Access”, supra note 1 at 136. Ruby Dhand, "Creating a cultural analysis tool for the implementation of Ontario's civil mental health laws" (2016) 45 Int J of Law and Psychiatry 25 at 25 [Dhand "Creating"]. 53 54

12 higher dropout rates when placed on a Community Treatment Order (CTO) under the MHA.55 While technically voluntary, a CTO is often viewed as coercive as involuntary patients are told that they can only leave a mental health facility and receive treatment in the community if they agree to the terms of the CTO.56 Once a patient is issued a CTO, the MHA empowers psychiatrists to compel attendance to the mental health care facility if they suspect the patient is not complying with the terms of the CTO.57 If the patient does not appear within a set period, a warrant is issued, empowering the police to forcibly bring the person to the mental health care facility for treatment.58 As discussed earlier, this can be a demeaning and traumatic experience for ethno-racialized individuals in particular. Accordingly, efforts should be made to ensure ethno-racialized patients comply with CTOs and treatment plans to reduce the likelihood that they will be involuntarily held at a mental health care facility. Ethno-racialized individuals may be more likely to deviate from CTOs or treatment plans because they do not want to rely exclusively on Western medicine and would prefer to use Complementary or Alternative Medicines (CAM).59 Examples of CAM include: naturopathic healing, herbal remedies, spirituality, reiki, yoga, talk therapy, and acupuncture.60 According to Lyren Chiu and her colleaguesâ&#x20AC;&#x2122; study, spirituality acts as an incredibly powerful source of healing for East and South Asian women in Canada who are suffering from some form of psychosis.61 All of the women interviewed however, suggested that they used spirituality or other cultural healing methods such as Tai Chi, as a supplement to Western medicine, using CAM 55

Mfoafo-M'Carthy, supra note 10 at 2. Ibid. 57 Mental Health Act, supra note 2 ss 33.3(1). 58 Mental Health Act, supra note 2 ss 33.3(3). 59 Tetyana Pylpiv Shippee, Markus H Schafer & Kenneth F Ferraro, "Beyond the barriers: Racial discrimination and use of complementary and alternative medicine among Black Americans" (2012) 74 Social Science & Medicine 1155 at 1155 [Shippee & Schafer & Ferraro]. 60 Ibid. 61 Chiu et al, supra note 16 at 645. 56

13 mostly to manage the side-effects of their medicine.62 In expressing the relationship between their spirituality and medicine, many woman suggested that they “both work hand in hand, not alone.” 63 That said, most of the women also indicated that they would prefer traditional healing methods if they were accessible and affordable.64 Some of the women expressed a preference for doctors of their own ethno-racial background, presumably because this would make them feel more comfortable and perhaps because they believed doctors of the same ethno-racial background would have more knowledge of traditional healing practices.65 This finding was supported by Daniel E. Jimenez and his colleagues’ study, which found Asians tend to prefer mental health care workers of the same ethno-racial background as them.66 Lyren Chieu and her colleagues’ study suggests that ethno-racialized patients may want to use culturally appropriate CAM to supplement or replace Western medicine.67 If ethnoracialized individuals believe CAM is effective, they may be choose to ignore treatment plans prescribed by mental health care practitioners that focus exclusively on Western medical models of treatment, resulting in higher rates of noncompliance and involuntary treatment. Ethno-racialized individuals may also be more likely to deviate from treatment plans out of mistrust for Western medicine and institutions. A study by Tetyanai Plypiv Shippee, Markus H. Schafer and Kenneth F. Ferraro for example, found Black Americans who experienced

Ibid. Chiu et al, supra note 16 at 648. 64 Ibid. 65 Ibid. 66 Daniel E Jimenez et al., "Cultural Beliefs and Mental Health Treatment Preference of Ethnically Diverse Older Adult Consumers in Primary Care" (2012) 26:6Am J Geriatr Psychiatry 533 at 53 [Jimenez et al.] 67 Chiu et al, supra note 16 at 648. 63

14 discrimination were twice as likely to report using CAM.68 The authors suggest that ethnoracialized individuals may be more likely to question psychiatrists and mistrust Western medical models more generally because of the discrimination they have experienced, resulting in a preference for CAM.69 Given this preference, psychiatrists should try to incorporate CAM options as much as possible when treating ethno-racialized individuals who express similar preferences to ensure higher rates of treatment compliance. Incorporating CAM into treatment plans for ethno-racialized individuals may also foster trust between the ethno-racialized patient and psychiatrist. By incorporating CAM, psychiatrists demonstrate to ethno-racialized patients that they are not bound by Western medical models and the institutional framework that many ethno-racialized individuals mistrust. If psychiatrists foster a sense of trust, the patient may be more likely to adhere to proposed treatments. In contrast to the cases discussed above however, some cultural groups express a desire for medication, rather than CAM. For example, in Jimenez and his colleaguesâ&#x20AC;&#x2122; study, Latinos expressed a preference for medication as opposed to CAM as a result of the consistency medication provides.70 Accordingly, mental health care practitioners must consider the cultural backgrounds of each ethno-racialized patient when deciding (1) whether to incorporate CAM in their treatment plan and (2) what type of CAM is appropriate and desired by the ethno-racialized patient. Considering culturally appropriate treatment plans is likely to foster a sense of trust in psychiatrists and in the efficacy of their treatment, leading to higher rates of compliance and improving the mental health care of ethno-racialized patients.

Shippee & Schafer & Ferraro, supra note 58 at 1158. Shippee & Schafer & Ferraro, supra note 58 at 1156. 70 Ibid. 69

15 SECTION 2: RECOMMENDATIONS FOR IMPROVING CARE Having discussed three barriers ethno-racialized individuals face in receiving appropriate mental health care, this section will now propose a series of recommendations to improve the practice of psychiatry and the legal framework that governs the mental health care of ethnoracialized individuals in Ontario. Although these recommendations are by no means comprehensive, they provide a useful outline of some key changes which would greatly improve the mental health care of ethno-racialized individuals. 1. Improving Access by Incorporating Mental Health Services in Family Clinics To reduce the rate at which ethno-racialized individuals are presented to emergency departments involuntarily by the police, access to mental health care must be improved. As discussed under the Barrier 1 section, a number of studies have found ethno-racialized individuals are more likely to seek help from family physicians than mental health professionals.71 Introducing integrated medical teams on a wide scale basis, where social workers, community educators and mental health professionals work out of the same clinic as family physicians, could improve access to mental health services by providing a â&#x20AC;&#x153;one stop shopâ&#x20AC;? for ethno-racialized individuals.72 It is essential that all of these services be covered under OHIP to ensure financial barriers do not impede access.73 Along with reducing physical and financial barriers to access, integrating mental health care with family clinics could also reduce barriers related to stigma as ethnoracialized individuals could rationalize that they are seeing their family doctor, which is culturally acceptable, and not a mental health care worker specifically.74

Tieu & Konnert, supra note 3 at 143. Islam et al., supra note 21 at 1. 73 Islam et al., supra note 21 at 8. 74 Ibid. 72

16 To further reduce the stigma that prevents ethno-racialized individuals from accessing mental health care services, and from fully disclosing all of their symptoms when they do access services, advocates and community educators should provide information sessions on mental health and stigma at these integrated family clinics.75 These sessions should be provided in English as well as in different languages periodically throughout the year to ensure ethnoracialized individuals who do not speak English also access this information. Further, along with conducting information sessions in family clinics, advocates should also deliver these sessions in the community, delivering information to particular ethno-racial groups at cultural heritage sites or community centres.76 Some of these changes could be introduced through amendments to the MHA. It is recommended that the MHA be amended to confer positive rights onto individuals suffering from mental illness. These rights should include the right to services and supports, including advocacy services.77 The conferral of positive rights would protect the rights of ethno-racialized individuals, who are disproportionately denied services and access to mental health care.78 H Archibald Kaiser proposes that mental health legislation should also include a preamble which outlines the guiding principles of the legislation.79 One of the guiding principles suggested is to provide individuals with “services and supports in the least restrictive, least onerous and least intrusive manner.”80 The MHA should be amended to introduce a guiding principle such as

Islam et al., supra note 21 at 1. Kwame McKenzie et al., "Report to the Mental Health Commission of Canada" (2016) at 17. 77 H Archibald Kaiser, “Imagining An Equality Promoting Alternative to the Status Quo of Canadian Mental Health Law” (2003) Health Law Journal 185 at 194 [Kaiser]. 78 Ibid. 79 Kaiser, supra note 77 at 193. 80 Kaiser, supra note 77 at 192. 76

17 the one proposed by Kaiser to provide a legislative basis for the creation of a comprehensive family health team.81 Integrating mental health care services with family clinics would improve access to mental health care for ethno-racialized individuals, addressing Barrier 1. This proposal would also reduce stigma, increasing the likelihood that ethno-racialized patients will openly disclose symptoms and concerns of mental illness. This would improve the diagnoses and treatment of ethno-racialized patients, addressing Barriers 2 and 3. 2. Improving Care Through Cultural Awareness Training Along with creating integrated health care facilities, mental health service providers should be obligated to take annual cultural awareness training courses as a part of their professional development requirements. To ensure compliance, the Consent and Capacity Board (CCB), the body tasked with reviewing involuntary treatment orders and CTOs under the MHA, should be empowered to question psychiatrists to ensure that they have satisfied the cultural awareness training requirements prior to diagnosing or treating ethno-racialized patients.82 These courses should adopt an intersectional approach which recognizes the various overlapping identities ethno-racialized individuals embody.83 The courses should provide a framework for helping psychiatrists facilitate dialogue with ethno-racialized patients about their cultural beliefs and values. Cultural awareness courses should emphasize the need to identify culturally relevant barriers and facilitators to the patientâ&#x20AC;&#x2122;s understanding of their own mental condition.84 The courses should also encourage psychiatrists to work in a collaborative fashion with patients, so that psychiatrists seek both to learn from the patient, as well as to teach the

Ibid. Dhand "Creating", supra note 53 at 41. 83 Williams et al., supra note 32 at 1147. 84 Mizock & Russinova, supra note 30 at 235. 82

18 patient about mental illness to reduce any stigma or misconceptions the patient may hold.85 Generalizations should be avoided and each individual should be assessed on a case by case basis.86 Cultural awareness training courses should also encourage psychiatrists to facilitate a discussion of CAM with ethno-racialized patients. In as far as practicable, psychiatrists should be encouraged to accommodate requests for CAM without compromising their professional integrity or the individualâ&#x20AC;&#x2122;s health.87 If the psychiatrist feels Western medical treatment is necessary, they should be provided with the necessary tools to explain to ethno-racialized patients why the treatment is necessary and to explore how alternative treatment methods can be used in conjunction with medicine (as long as the two do not conflict). Where no accommodation of CAM is possible, psychiatrists should focus on explaining why that is the case to help foster a sense of commitment in the individual towards their treatment plan. If a psychiatrist doubts the information provided by an ethno-racialized patient regarding their culture, the psychiatrist should be obligated to consult practitioners or organizations that have cultural insights.88 At the same time however, cultural awareness courses should stress that, although psychiatrists should consider an individualâ&#x20AC;&#x2122;s cultural and racial background when diagnosing them, this does not mean the psychiatrist should defer to the individual or fail to diagnose someone with mental illness when symptoms are presented. Rather, psychiatrists must adhere to professional standards and make appropriate diagnoses having considered all relevant

Carolyn Shimmin et al., "Moving towards a more inclusive patient and public involvement in health research paradigm: the incorporation of a trauma informed intersectional analysis" (2017)17 BMC Health Services Research 539 at 540[Shimmin et al.] 86 Ruby Dhand, "Colliding Intersections in Law: Culture, Race and Mental Health" (2016) The Annual Review of Interdisciplinary Justice Research 100 at 113 [Dhand "Colliding"]. 87 Dhand "Creating", supra note 53 at 37. 88 Ibid.

19 criteria—which, as the evidenced by the research outlined above, includes cultural values and beliefs. Along with emphasizing the need to keep an open mind, cultural awareness courses should also emphasize the need for reflexivity.89 Psychiatrists should understand the “centrality of whiteness” in mental health institutions.90 Acknowledging their place in the predominately white, Western institutional framework of mental health care will help make psychiatrists more aware of any biases they hold and more open to the possibility that other treatment models exist in different cultures.91 Finally, it is important that cultural awareness courses include and emphasize the role of race in mental health. According to Suman Fernando, one of the most effective “manoeuver[s] by which psychiatry conceals, defends and maintains racism is that of ‘culturising’ it.”92 The field of psychiatry tends to focus on a patient’s cultural values at the expense of their racial identity.93 This leads psychiatrists to believe that the source of the patient’s mental illness is their ‘backward’ cultural values, as opposed to ethno-racial biases inherent in the field.94 This concern was also expressed by Ruby Dhand who suggests that psychiatrists may essentialize mental illness and label an ethno-racialized individual’s cultures as ‘inferior.’95 To avoid this, cultural awareness courses should encourage psychiatrists to identify and acknowledge the inherent biases they have as a result of their social locations and racial backgrounds. These biases must be

Shimmin et al., supra note 83 at 543. Jennifer Wood & K Bruce Newbold, "Provider Perspectives on Barriers and Strategies for Achieving Culturally Sensitive Mental Health Services for Immigrants: A Hamilton, Ontario Case Study" (2012) 13 Int Migration & Integration 383 at 387 [Wood & Newbold]. 91 Ibid. 92 Fernando, supra note 37 at 130. 93 Ibid. 94 Ibid. 95 Dhand "Colliding", supra note 84 at 103. 90

20 acknowledged before a psychiatrist can be truly open to understanding a patientâ&#x20AC;&#x2122;s cultural context. Introducing mandatory cultural awareness training requirements for psychiatrists would reduce the negative experiences ethno-racialized individuals have in mental health care facilities, improving access and addressing Barrier 1. Cultural awareness training requirements would also encourage psychiatrists to understand how cultural factors influence symptoms and treatment preferences, reducing misdiagnoses and noncompliance with treatment, addressing Barriers 2 and 3. 3. Ensuring Accountability in Service Delivery To consolidate and enforce some of the guiding principles related to culturally appropriate training discussed above, a Cultural Analysis Tool (CAT) should be incorporated into the MHA.96 The MHA should give jurisdiction to the CCB to review a psychiatristâ&#x20AC;&#x2122;s diagnosis to ensure the psychiatrist considered cultural factors in accordance with guiding principles established by the CAT.97 The CCB should also be mandated to adhere to the standards set out in the CAT.98 Although there are a number of analytic tools which could be adopted, the CAT created by Ruby Dhand in consultation with mental health consumer/survivors, lawyers, and mental health professionals is the most comprehensive and should be implemented across Ontario.99 The CAT created by Dhand provides a series of questions at each stage of mental health care and treatment, to ensure cultural factors are considered.100

Dhand "Creating", supra note 53 at 25. Ibid. 98 Ibid. 99 Ibid. 100 Ibid. 97

21 In terms of diagnosis, the CAT asks whether the psychiatrist addressed intersectional issues relevant to the client, received cultural awareness training, and asked probing questions to understand the degree of involvement the ethno-racialized patient has to their culture.101 The CAT also specifically addresses whether a psychiatrist considered cultural standards of normality and abnormality, and whether they identified cultural factors when determining an ethnoracialized patient as incompetent.102 If the CCB finds a number of the cultural factors identified by the CAT were not considered by the psychiatrist, they should order a reassessment of the ethno-racialized patient by another psychiatrist to avoid misdiagnosis. If the psychiatrist failed to comply with the CAT and the ethno-racialized patient presents evidence regarding their cultural beliefs however, the CCB should be able to use their discretion to decide whether the individual is capable to avoid delays.103 Along with holding psychiatrists accountable, implementing a CAT will also make the CCB more accountable. The CCB should be mandated to adhere to the principles of the CAT, including principles rejecting a preference for Western medical models over culturally suited CAM.104 A number of academics suggest that the CCB tends to uphold involuntary treatment orders when a patient refuses treatment as their refusal is considered an indicator of their incapacity.105 This tendency reflects a bias towards Western medical models.106 To obviate this bias, CCB members should consider treatment options that incorporate CAM as a part of the

101

Dhand "Creating", supra note 53 at 36-37. Dhand "Creating", supra note 53 at 37. 103 Ibid. 104 Dhand "Creating", supra note 53 at 27. 105 Dhand â&#x20AC;&#x153;Accessâ&#x20AC;?, supra note 1 at 129. 106 Ibid. 102

22 requirement to adhere to the guiding principles of the CAT.107 To support this objective, CCB members should be required to take some sort of course on the benefits of CAM and how treatment models are culturally situated. Incorporating the CAT into the MHA to ensure accountability will lead to fewer misdiagnoses based on a failure to consider cultural factors, addressing Barrier 2. Introducing the CAT will also increase treatment plans that incorporate CAM, reducing noncompliance and addressing Barrier 3. 4. Restricting the use of CTOs and Involuntary Admission Finally, to address the disproportionate rate at which ethno-racialized groups are involuntarily presented to mental health care facilities, the MHA should be amended to assert that involuntary presentation by the police should be treated as a last resort, once all other reasonable de-escalation methods have been exhausted.108 For example, the police should be obligated to attempt to locate the ethno-racialized individualâ&#x20AC;&#x2122;s family members to see if they can help deescalate the situation or if they are able to take the individual to the hospital to avoid the demeaning and traumatic experience of coercive admission to a mental health care facility by a police escort. Additionally, the MHA should be amended to stipulate that psychiatrists should only issue a CTO for ethno-racialized patients when they feel it is absolutely necessary.109 As discussed earlier, CTOs are viewed as coercive measures that disproportionately lead to police involvement with ethno-racialized patients.110 Instead of issuing CTOs, psychiatrists should try

107

Ibid. Kaiser, supra note 77 at 203. 109 Magnus Mfoafo-M'Carthy & Wes Shera, "Beyond Community Treatment Orders: Empowering Clients to Achieve Community Integration" (2013) 41:4 Intl J Ment Health 62 at 71 [Mfoafo-M'Carthy & Shera]. 110 Mfoafo-M'Carthy, supra note 10 at 6. 108

23 and implement Assertive Community Treatment (ACT) plans.111 Similar to CTOs, ACTs provide community psychiatric services to individuals who suffer from persistent mental illness.112 ACTs involve a psychosocial needs assessment, individualized and monitored treatment plans, and referrals to appropriate services for support.113 Unlike CTOs however, ACTs are voluntary and are not coercively enforced by legal orders.114 When implementing ACTs, psychiatrists should ensure that treatment plans are culturally sensitive and incorporate CAM. Psychiatrists should also try to incorporate Multi Family Psycho-Education Groups (MFPEG) with ACTs for ethno-racialized patients.115 MFPEGs involve education sessions for the family members of patients suffering from mental illness with the objective of aiding the patientâ&#x20AC;&#x2122;s recovery at home and reducing any stigma within the family.116 A study by Wendy Chow and her colleagues assessed the use of MFPGs in a culturally diverse ACT context, where two Chinese and Tamil families whose loved ones were on an ACT plan attended monthly education sessions.117 The MFPEG sessions were led by the same clinicians who treated the mentally ill family member under the ACT. 118The authors of the study found that attending MFPEG sessions reduced perceptions of family burden and mental health

111

Mfoafo-M'Carthy & Shera, supra note 107 at 73. Ibid. 113 Ibid 114 Rotenberg et al., supra note 4 at 140. 115 Wendy Chow et al, "Multi-Family Psycho-Education Group for Assertive Community Treatment Clients and Families of Culturally Diverse Background: A Pilot Study" (2010) 46 Community Ment Health 364 at 364 [Chow et al]. 116 Chow et al, supra note 113 at 365. 117 Ibid. 118 Ibid. 112

24 related stigma, and increased levels commitment to maintaining their loved one’s treatment plan.119 Although ACTs and MFPEGs require a great deal of commitment from clinicians and psychiatrists, they may increase commitment to treatment in ethno-racialized communities. MFPEGs have the added benefit of reducing stigma in a particular family, which over time, may lead to greater acceptance of mental illness within a particular community.120 Additionally, when families are more invested in their loved one’s mental health, they are more likely to intervene if they notice their loved one has stopped taking their medicine, reducing the likelihood of police involvement.121 Family interventions have been shown to increase adherence to treatment plans and to reduce the risk of relapse by 15-25%.122 Along with psychiatrists implementing ACTs as opposed to CTOs and treating CTOs as a last resort, the CCB should be more critical of CTOs. The MHA should be amended to empower the CCB to question whether the treatment outlined in the CTO is culturally appropriate.123 In the Supreme Court of Canada’s decision in Mazzei v. British Columbia, the Court held that although Non-Criminally Responsible review boards cannot prescribe treatment, they should require Directors of psychiatric facilities to “undertake assertive efforts to enroll the accused in a culturally appropriate treatment program.”124 Unfortunately, the CCB has not applied similar principles to interpreting its mandate.125 Accordingly, such powers should be explicitly conferred onto the CCB as a safeguard for ethno-racialized patients and to foster adherence to treatment

119

Chow et al, supra note 113 at 367-368. Chow et al, supra note 113 at 367. 121 Chow et al, supra note 113 at 368. 122 Chow et al, supra note 113 at 365. 123 Dhand "Creating", supra note 53 at 38. 124 Mazzei v. British Columbia (Director of Adult Forensic Psychiatric Services), 2006 SCC 7 at para 61, 264 DLR (4th). 125 Dhand "Creating", supra note 53 at 30. 120

25 plans.126 That is not to say however, that the CCB should reject any CTOs that do not involve CAM, but rather, the CCB should be required to assess whether the psychiatrist at least considered CAM in the CTO in light of the individualâ&#x20AC;&#x2122;s cultural beliefs and preferences. Amending the MHA so that CTOs and involuntary admission to a mental health care facility by the police are treated as a last resort, and so that the CCB is required to assess whether CTOs are culturally appropriate predominantly addresses Barrier 3. Introducing non-coercive treatment plans such as ACTs and MFPEGs will increase treatment conformity by considering cultural factors. Conclusion As Ontario becomes increasingly racially and ethnically diverse with the arrival of new immigrants every day, it is imperative that the mental health care system be strengthened to better accommodate the unique needs and challenges faced by ethno-racialized groups. This paper has attempted to identify some of the challenges and barriers to appropriate mental health care ethno-racialized individuals face, including barriers to access, diagnosis and treatment. It is important to recognize however, that there are a number of significant barriers that have not been discussed in this paper, such as those related to language interpretation and immigration status.127 Although the issues and recommendations proposed in this paper are limited in their scope, they provide a useful starting point for improving the rights of ethno-racialized groups.

126 127

Ibid. Hampton & Sharp, supra note 26 at 1898.

26 BIBLIOGRAPHY LEGISLATION Mental Health Act, RSO 1990, c M.7[Mental Health Act].

JURISPRUDENCE Mazzei v. British Columbia (Director of Adult Forensic Psychiatric Services), 2006 SCC 7, 264 DLR (4th). SECONDARY MATERIAL Chiu, Lyren et al, "Spirituality and Treatment Choices by South and East Asian Women with Serious Mental Illness" (2005) 42:4 McGill University 631. Chow, Wendy et al. "Multi-Family Psycho-Education Group for Assertive Community Treatment Clients and Families of Culturally Diverse Background: A Pilot Study" (2010) 46 Community Ment Health 364. Dhand, Ruby. "Access to Justice for Ethno-Racial Psychiatric Consumer/Survivors in Ontario" (2011) 29 Windsor Y B Access Just 127 128. Dhand, Ruby. "Colliding Intersections in Law: Culture, Race and Mental Health" (2016) The Annual Review of Interdisciplinary Justice Research 100. Dhand, Ruby. "Creating a cultural analysis tool for the implementation of Ontario's civil mental health laws" (2016) 45 Int J of Law and Psychiatry 25. Fernando, Suman. Race and Culture in Psychiatry (London: Routledge, 1988). Hampton, Nan Zhang & Seneca E Sharp. "Shame-Focused Attitudes Toward Mental Health Problems: The Role of Gender and Culture" (2014) 57(3) Rehabilitation Counseling Bulletin at 1897. Islam, Farah et al., "Mental Health Consultation Among Ontario's Immigrant Populations" (2017) Community Ment Health J 1.

27 Jimenez, Daniel E et al. "Cultural Beliefs and Mental Health Treatment Preference of Ethnically Diverse Older Adult Consumers in Primary Care" (2012) 26:6Am J Geriatr Psychiatry 533. Kaiser, H Archibald. â&#x20AC;&#x153;Imagining An Equality Promoting Alternative to the Status Quo of Canadian Mental Health Lawâ&#x20AC;? (2003) Health Law Journal 185. McKenzie, Kwame et al. "Report to the Mental Health Commission of Canada" (2016) at 17. McKenzie, Kwame. "Issues and Options for Improving Services for Diverse Populations" (2015)34:4 Canadian J of Community Ment Health 69. Mfoafo-M'Carthy, Magnus. "Community treatment orders and the experiences of ethnic minority individuals diagnosed with serious mental illness in the Canadian mental health system" (2014) 13 Int J for Equity in Health 1. Mfoafo-M'Carthy, Magnus & Wes Shera. "Beyond Community Treatment Orders: Empowering Clients to Achieve Community Integration" (2013) 41:4 Intl J Ment Health 62. Mizock, Lauren & Zlatka Russinova, "Racial and Ethnic Cultural Factors in the Process of Acceptance of Mental Illness" (2013) 56:4 Rehabilitation & Counselling Bulletin 229. Rotenberg, Martin et al. "The role of ethnicity in pathways to emergency psychiatric services for clients with psychosis" (2017) 17 BMC Psychiatry 137. Shimmin, Carolyn et al., "Moving towards a more inclusive patient and public involvement in health research paradigm: the incorporation of a trauma informed intersectional analysis" (2017)17 BMC Health Services Research 539. Shippee, Tetyana Pylpiv, Markus H Schafer & Kenneth F Ferraro. "Beyond the barriers: Racial discrimination and use of complementary and alternative medicine among Black Americans" (2012) 74 Social Science & Medicine 1155.

28 Tieu, Yvonne & Candace A Konnert. "Mental health help-seeking attitudes, utilization, and intentions among older Chinese immigrants in Canada" (2014) 18:2 Aging & Ment Health 140. Williams, Charmaine C et al. "Depression and discrimination in the lives of women, transgender and gender liminal people in Ontario, Canada" (2017) 25:3 Int Migration & Integration 1139. Wood, Jennifer & K Bruce Newbold. "Provider Perspectives on Barriers and Strategies for Achieving Culturally Sensitive Mental Health Services for Immigrants: A Hamilton, Ontario Case Study" (2012) 13 Int Migration & Integration 383. Zaheer, Juveria et al. "I just couldnâ&#x20AC;&#x2122;t step out of the circle. I was trapped': Patterns of endurance and distress in Chinese-Canadian women with a history of suicidal behaviour" (2016)160 Social Science & Medicine 43.

CANADIAN RACE RELATIONS FOUNDATION