1 Accessing Mental Health Services for Newcomers in Alberta: An Environmental ScanSeptember 2017

2 Syrian Youths in CanadaOne of their challenges is the education system in Canada. They must learn English or French or both to be able to participate actively through the school year.

3 Acknowledgement AAISA Milton Ortega, Stephanie Kot, Amy Crofts MMK RESEARCH AND CONSULTING Dr. Michael Kariwo, University of Alberta; Dr. Edward Makwarimba, Alberta Health Services, Dr. Edward Shizha, Wilfrid Laurier University. Funder IRCC We would like to thank all participants who shared their stories with us.

4 Partner OrganizationsWe wish to acknowledge AAISA member organizations, Alberta Health Services, as well as service providers including Africa Centre, Edmonton Mennonite Centre for Newcomers and Multicultural Health Brokers for providing useful information and contacts.

5 Overview Preamble Introduction Background Methodology FindingsRecommendations & Implications for the Sector

6 Preamble In January this year (2017) AAISA partnered with MMK Research and Consulting to undertake a study on mental health services in Alberta and to assess the access that refugee and non-refugee immigrants have to these services We are presenting the results of this investigation

7 Introduction Project undertaken by AAISA with funding from IRCC in collaboration with MMK Research and Consulting. The assessment was conducted between January and March 2017. Study purpose: To better understand the need for mental health services and programs and services designed to support newcomer settlement and integration, and the corresponding organizational and system capacity in Alberta. Generate evidence to guide decision-making and improve program and service planning. Key areas of focus: mental health service provision, language, cultural competency, integration, and social connections

8 Why Focus on Refugees and Non-Refugee immigrantsBetween 2006 and 2011 alone 1,162,900 foreign-born people immigrated to Canada. While immigrants were predominantly from Europe and then Eastern Europe since confederation, immigration has lately, particularly during the past five years, been largely from Asia (including the Middle East). The share of immigration from Africa, Caribbean, Central and South America has also increased in the past ten years. Political conflicts in many parts of Eastern Europe and Africa has also fueled the tide of refugees from these countries to neighbouring countries and industrialized countries such as Canada.

9 Background Canada has admitted the largest number of refugees in a single year in nearly four decades, according to the Office of the United Nations High Commissioner for Refugees. The resettlement of 46,700 refugees in 2016 marks a “tremendous achievement” and a record for Canada since 1978, when the Immigration Act came into effect, the UNHCR representative in Canada said Monday. (CTV News April 24)

10 Background According to the UNHCR, the top five countries of origin in 2016 were: Syria: 33,266 Eritrea: 3,934 Iraq: 1,650 Congo: 1,644 Afghanistan: 1,354

11 Significance/ImportanceHealthy migrants are well-integrated migrants, as their sense of well-being affects their families, workplaces, schools their social interlocutors. The Director General for the International Organization for Migration (IOM) aptly summed the business case for promoting the health and mental well-being of newcomers by saying: The contribution migrants make to the social and economic development of both their countries of origin and destination is only made possible if migrants are physically and mentally healthy, regardless of their migration status

12 Background In Canada, one in every three people will experience a mental health problem at some point in their lifetime. For members of various ethno-cultural communities, language and cultural differences make it especially difficult for people to seek out and find the mental health support they need. This is despite the fact that newcomers, including refugees, are particularly vulnerable to mental health illnesses: “separation from family, loss of support, language barriers, cultural adjustments and challenges in finding a home, work and community all contribute to stress and make a person more vulnerable to mental health issues.”

13 Background Since Canada is a diverse country, with millions of people from many backgrounds and cultures and speaking more than 200 languages, it can be challenging to provide mental health services and supports to such a diverse population. Numerous studies across the country have noted huge gaps in service provision.

14 Background Currently, existing mental health services in Canada are deemed ill-prepared to deal with immigrants and refugees with mental problems because of key challenges (e.g., language, culture, social isolation) and the resettlement hurdles they face. The Alberta Government (2015) reported gaps existing in the system with regard to adequate and appropriate addiction and mental health services for Albertans. The challenge then, is to find the best ways to make available and accessible mental health services to Alberta’s diverse population.

15 Background In-line with national health policy and the growing need for relevant mental health support and service provision for refugees and immigrants, AAISA initiated the “Accessing Mental Health Services in Alberta” research project to assess the diversity of services available to newcomers and offer a breakdown of accessibility

16 Methodology Review of literature on mental health services in Canada.Conducted a scan of existing programs and services already in place to support mental health needs relevant to newcomers within the ambit of Alberta Health Services, Resettlement Assistance Programs (RAP), community health services, and language training, as well as other resettlement and support services. Interviews with Syrian refugees n=28 and representatives from health and immigrant serving organizations n=19 in Alberta.

17 Theoretical FrameworkA holistic approach was taken in the study Social determinants of health Psychology Clinical

18 Environmental Scan We conducted a scan of 85 service provider organizations in Alberta. The objective was to find services provided and map those that were focused on mental health. Details of findings are in the full report.

19 Defining Mental HealthThe WHO leads the way in various ways with regards to definitions and conceptualizations of all things related to health and well-being. In its key documents and constitution, the WHO articulates a positive dimension of mental health in its definition of health. According to the WHO, “Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity", (our emphasis). Hence ‘mental health’ is part of that sum called ‘health’. A significant implication of this definition also is that mental health is more than just the absence of mental disorders or disabilities. It has a lot to do with our ability to carry out our daily functions, enjoy life, and deal with daily challenges. This makes mental health an integral part of one’s overall health.

20 Definitions The Public Health Agency of Canada has a similarly inspiring definition, pointing out the importance of everyone’s “…ability to feel, think, and act in ways that enhance our ability to enjoy life and deal with the challenges we face…”

21 Definitions: Socio-Cultural DifferencesOn the other hand, a few participants reported of narrower conceptualizations of mental health in their organizations. For example, one participant stated that their agency defined it in medical terms: [M]ore associated with medication or clinical aspect…assessment… when we are hearing of mental health, we think of mental illness, mental depression, mental stress, areas in which you need assessment by a psychologist or therapist…we have made a distinction between mental health and mental wellbeing. That is an important distinction, because there is a limited medical usage of mental health (Participant C).

22 Definitions-Cultural sensitivityOne Service Providing Organization reported that there is an opportunity for a culturally inclusive definition of mental health. If a newcomer believes their mental health issues are being caused by, for example, racism they are experiencing in school, the solution is worked out to solve racism, and not providing some psychotherapy to the newcomer.

23 Limitations Accessing and recruitment of participants due to FOIPStigma around the topic

24 Methodology Quantitative data was collected to show distribution of services. A brief survey was conducted to show how refugee immigrants and non-refugee immigrants perceived access to mental health services.

25 Methodology Qualitative data was collected through: a) Literature reviews b) In-depth interviews with individual refugee and non-refugee immigrants (n=28) c) Interviews with representatives of organizations providing services (n=19).

26 Interview Questions - Individual Refugees and Immigrants1) Have you ever accessed mental health services in Alberta? 2) Can you tell me about services that you attend for support in mental health? 3) Why do you attend these services and what type of help do you get? 4) When did you last access the services? 5) Where did you access the service, (location and organization)? 6) Why did you choose that location? 7) How did you know about the organization? 8) How frequently do you access these services (i.e., per week/month/year)? 9) How easy or difficult is it to get these services? Probe; language, culture, finances, transportation, service providing staff etc.

27 Interview Questions 10) On a scale of 1 to 5 (1-very dissatisfied, 2- dissatisfied, 3-neutral, 4-satisfied, 5- very satisfied), please rate your satisfaction with: Distance to service Quality of service Relevancy of service Language of service Competency of staff Meeting your cultural needs Meeting your mental health needs/expectations 11) What improvements can you suggest to improve access, relevance and quality of service, and competency of staff? 12) Is there anything else which you wish to share regarding this topic?

28 Interview Questions – Organizations Providing Mental Health Services1) What type of services does your organization provide? 2) Do you have a unit or section that provides mental health services? 3) How does your organization define “mental health”? 4) Which services do you provide focus on mental health? 5) Who provides these services? Are there adequate human resources? 6) What is the composition of your staff (gender, race, and ethnicity)? 7) What language are these services provided in? 8) How frequently do refugees and non-refugee immigrants access your services? 9) Are you able to give a breakdown in terms of gender age and ethnicity of your clients?

29 Interview Questions - Organizations Providing Mental Health Services10) What problems, if any, do your staff encounter when providing the services to the populations above? 11) What are the gaps in service provision when you consider other organizations dealing with mental health? 12) Do you get refugees/immigrants referred to you from other agencies /organizations for mental health assistance? If so, which organizations refer refugees/immigrants to you on a regular basis? 13) Do you refer refugees/immigrants to other organizations for mental health services? If so, which organizations do you refer to? 14) What improvements could be made to service provision from a Provincial perspective? 15) Is there anything else which you wish to share regarding this topic?

30 Findings The distribution of human resources favours metropolitan cities of Calgary and Edmonton. The distribution of human resources reveals that metropolitan areas, Calgary and Edmonton, have the highest number of physicians (Calgary: n=3,076 [41%] and Edmonton: n= 2,659 [35%] for) and AHS employees (Calgary: n= 37,000 [37%] and Edmonton: n= 32,657 [33%]). The statistics indicate that 76% of doctors and 70% of AHS employees are in big cities while the remainder in small cities and rural communities.

31 Findings The health workers who are employed by AHS include those who provide mental health care in the province. In Edmonton, paramedics and mental health professionals work in partnership to offer crisis help in the community. Crisis Response and EMS (CREMS) teams a paramedic and a mental health therapist/ nurse who work collaboratively with mental health crisis services and other addiction and mental health programs effectively engaging clients to meet their needs and provide treatment in the community avoiding unnecessary trips to the Emergency Department.

32 Health Professionals

33 Mental Health ProfessionalsLack of mental health professionals A lot of organizations providing settlement services to refugees and immigrants do not have specialized mental health professionals (e.g., psychologists, psychiatrists), and therefore refer clients to other agencies that are suitably staffed, and to private practitioners.

34 Findings – Service ProvisionThe scan results showed that AHS was the largest service provider. AHS is a province-wide health service provider that has community health services in all the five zones that divide the province. It provides services in both the metropolitan cities of Calgary and Edmonton, as well as in small cities and rural communities. The distribution of AHS’s facilities in these zones is as follows: the North Zone has the majority of the services (44%) followed by the Central Zone (26%), South Zone (12%), Calgary Zone (9%) and Edmonton Zone (9%). Calgary Zone and Edmonton Zone, which are the largest urban areas and where most refugees and immigrants are settled, have the lowest and an equal distribution of health care facilities. There are more facilities in Northern Alberta because of the many communities that are distributed over the region.

35 Findings – Service ProvisionMental health programs and services in Alberta are under AHS. These programs and services are offered at over 650 facilities throughout the province, including hospitals, clinics, continuing care facilities, cancer centres, mental health facilities and community health sites. The province also has an extensive network of community-based services designed to assist Albertans maintain and/or improve health status.

36 Findings – AHS Facilities

37 Findings – Distribution of Health Services

38 Findings – Supporting Mental HealthIn metropolitan Edmonton, the majority of services (64%) are specifically geared towards mental health needs, such as: addictions and substance abuse (3%), continuing care (11%), health system (12%), mental health and wellness (14%), social and family issues (21%), and wellness and lifestyle (3%). Other services also contribute to a more holistic support of the mental health needs, including: food and nutrition (7%), pregnancy and childbirth (10%), and rehabilitation and aids to daily living (16%).

39 Findings – Distribution of Health Services

40 Findings - Supporting Mental HealthIn Calgary, 74% of health services are specific to mental health needs, such as: addictions and substance abuse (7%), continuing care (9%), health system (9%), mental health and wellness (21%), social and family issues (26%) and wellness and lifestyle (2%). Other services that complement mental health needs are rehabilitation and aids to daily living (14%), pregnancy and childbirth (5%), and food and nutrition (3%).

41 Findings - Distribution of Health Services

42 Findings - Supporting Mental HealthFort McMurray is another small city in Northern Alberta where AHS provides 69% of mental health services and needs, including: addictions and substance abuse (11%), continuing care (6%), health system (8%), mental health and wellness (17%), social and family issues (24%) and wellness and lifestyle (3%). Furthermore, additional programs include rehabilitation and aids to daily living (14%), food and nutrition (8%) and pregnancy and childbirth (7%).

43 Findings AHS provides health care including mental health care to all Albertans who require the services, including newcomers who are refugees and immigrants. While mental health might be one of the main challenges faced by refugees and immigrants, only 7% of AHS’ services are targeted towards addiction and mental health. The other health services are acute care (24%), continuing care (68%), and community and palliative care (1%). However, AHS advises those seeking mental health services to go through community health centres, which are found across the province.

44 Survey Results

45 Qualitative Findings Causes of Mental Health ProblemsLanguage Barriers Transportation Wait Times for Services Quality of Services Communication with Service Providers

46 Causes of Mental Health IssuesSome refugee families are relocated without all of their family members. Some are displaced and relocated without their fathers and husbands, while refugee children might be separated from both parents. This separation can cause a breakdown in family structure and impact children and families not only in economic ways, but emotionally as well. Family separation impacts the well-being of refugees. Leaving family members behind, and going through the process of relocation alone, leads to intense anxiety for the safety of those left behind. Fear for family contributes more to current distress than traumatic memories, especially once refugees have arrived in their country of final relocation

47 Causes One participant reported that his mental health issues were being caused by separation from family members and the situation of those family members left back home. While they have been received and settled in Canada, they were concerned about members of the family left in Lebanon.

48 Causes “But our main mental health concern has to do with what we went through before coming to Canada. I have been away from my country, Syria, for 9 years, my dad is in Syria and I haven’t heard from you.” “We have other family members that I have not been in contact with for so long and I don’t know they are right now as we speak. I have two brothers in Lebanon who have not been registered with United Nations High Commissioner for Refugees (UNHCR), so they are on their own in Lebanon, without help from anybody. “ “My family and I arrived in Canada and were fine here. We get what we need – food, safety, school for our kids and for ourselves as parents, etc., but we don’t know if those we left home have even food to eat.”

49 Findings - Cultural RelevanceCultural Relevance is cited as one of the biggest challenges to providing mental health services that meet the needs of refugees and immigrants. This challenge is related to lack of knowledge of the nature and extent of trauma most clients went through before arriving in Canada. Defining the problem in a holistic way while considering root causes could help lead to appropriate referrals and supports.

50 Referrals The lack of professionals dedicated to the provision of mental health services in the organizations examined in this study resulted in an increased number of referrals to mainstream agencies. Agencies referred to include AHS, and some of the well-established agencies that have many branches across the province, such as Catholic Social Services. However, agencies also get referrals from other immigrant serving organizations that do not have the appropriate resources to deal with the mental health needs of newcomers. Family physicians also refer newcomers to refugee-serving agencies because of their expertise dealing with newcomers mental health needs, particularly where the agency has staff that speak the language of the newcomer seeking mental health services.

51 Communication & LanguageCommunication and language barriers were mentioned by all service providers, refugees and immigrants interviewed as key roadblocks to providing appropriate supports that meet newcomer mental health needs, even before concerns or worries develop into ‘issues’, or later into medical problems.

52 Other Challenges Other barriers to services include:Need for childcare provision Adequate transportation Wait times to access mental health professionals Stigma around mental health also makes it harder for people to accept that they have a problem that they need to get help for

53 Resources and CapacityCapacity refers to both human and capital resources of an organization. Lack of specialized mental health professionals led to a greater number of referrals and long wait times that can stall access to service provision. Coordination and collaboration challenges among providers negatively impacts the quality of referrals and prevents organizations from pooling resources when necessary.

54 Resources and CapacityPart and parcel of the human resource challenge is related to inadequate financial resources directed towards mental health problems among newcomers. Without sustainable funding, most agencies are in a continual cycle of applying for grants to stay afloat. Hence one says, “We need a lot of everything because there is a lot of demand,” (Participant L). “[We need] funding because the immigrants are coming…with huge mental health issues and we need funding to be able to meet their needs in the most effective way.” (Participant M) Other participants also mentioned the lack of resources on the part of newcomers as a reason for not accessing available mental health services. A key resource that many newcomers fall short on is transportation. Without transportation newcomers are not able to fully access mental health services when they want them. According to one participant: “It is quite difficult for refugees to keep appointments because of transportation difficulties.” (Participant J)

55 Resources “Our staff sometimes burn out because it’s just too much on them. For staff dealing with those stories it becomes a question of how much is too much.” “For example, I have one nurse who mainly helps with refugee intake work, and then I have two other people who have been trained to be able to do the same job in order for that … nurse to take a break … when it gets too much.” (Participant J)

56 Resources – Burnout As one participant mentioned, with prolonged provision of supportive care comes burnout. Service providers become fatigued and stressed out because of hearing and dealing with the traumatic stories of what refugees went through before reaching Canada. “[One] problem we see is that our staff are serving refugees who come with stories which are quite difficult because of the problems they carry with them and experiences they went through. These stories are quite stressful and impact on staff.”

57 Wait Times Largely tied to human and financial resource limitations, one of the key gaps preventing efficient provision of mental health services is wait times. According to a participant from AHS, the largest player in mental health services in the province: “…wait times to get in to see mental health professionals are long…and that’s probably one of the mental health gaps we are still struggling with.” (Participant J) This sentiment is echoed by a provider outside AHS, who also has the perception that accessing AHS mental health services is not easy, and says: “AHS is tricky to access and even more challenging for immigrants and refugees. There is a long wait list…The intake process needs to be simplified…to be relational to build rapport, trust, listening, a welcoming environment.” (Participant L)

58 Wait Times The wait time was also reported by a participant from Syria who said that the wait times to see a psychologist are long. The participant blamed bureaucracy within some mental health services for the long delays in seeing specialists or professionals by those seeking help.

59 Wait Times “My family doctor tried his best to contact the mental health specialist - psychologist and psychiatrist and managed to make an appointment to meet the specialist after nine months. It’s a killing long wait; it’s a killing bureaucracy. “ “I have to wait nine months just to meet the specialist. Fortunately the 9 month wait is coming to end, as the appointment is finally arriving on 27 March.”

60 Crisis Intervention GapsSome participants reported that there are no quick solutions when emergencies happen.

61 Holistic Approach The lack of treating mental health in a holistic way in service delivery is also blamed on the wider Western culture, which emphasized treatment of symptoms. The lack of cultural definitions of mental health and wellness in the western medical field poses challenges for refugees and immigrants. The meaning may be in the deep-seated attitudes and beliefs a culture holds about whether an illness is "real" or "imagined," or whether it is of the body or the mind (or both). Therefore, understanding individual and cultural beliefs about mental illness is essential for the implementation of effective approaches to mental health care.

62 Culture In ethno-cultural societies, mental health is holistic in terms of ‘mind, body, and spirit.’ There are different explanations for what might be perceived mental illness. People who hear voices might be defined as gifted – the supernatural worldview. In Chinese culture, mental illness is purification of the spirit-someone might not seek help until it is too late (Participant H).

63 Recommendations Professionalization: Training for clinicians and para-professionals in cultural competency to allow for greater diversity and inclusion.

64 Recommendations for Service OrganizationsCultural competency by service providers Easier navigation through services Better management of referrals A holistic approach to service provision

65 Recommendations for PolicyA coordinated policy framework helps to harmonize services and programs. The findings of this study acknowledge that there is an overall consensus among partners and stakeholders about the challenges of effectively coordinating the services and programs. Therefore, there is the need for an integrated and coordinated approach to service provision and programming for newcomers at all levels. Agencies and organizations that serve refugees and immigrants should work with all levels of government (local, provincial and federal) to develop client and evidence-based policies.

66 Recommendations for PolicyImproved connection/communication between gate keepers and mental health service providers Improved funding for agencies and other service providers.

67 Holistic Approach Holistic approach to mental health/illness treatmentClinical diagnosis should be done under global approach where psycho-social therapy plays a role.

68 System Review A need for clear pathways to accessing mental health services; better coordination between service providers, policy makers and the clients.

69 Research Suggestions The study highlighted several key areas that require further exploration and investigation. There are very complex issues involving mental health in Alberta. A more in-depth study using bigger sample sizes would yield more generalizable results and further insights. The findings would be generalizable to other regions not covered by individual and organization interviews, and would provide a robust framework for policy makers and guidelines for service providers. A study to map pathways for service provision is a desirable first step to make service provision more efficient.

70 Thank You Questions?? Please type them in chat box

71 Questions & DiscussionWe want to know your input on the topic What are your reactions to the findings? What are your experiences with the issues at stake e.g. access to services , language barrier, staffing, funding etc.