Theoretical Background

In just one generation the ethno-racial composition of Canadian society has shifted dramatically. This cultural diversity is most keenly experienced in urban centres. Toronto is Canada ’s most multicultural city, receiving over 100 000 immigrants from around the world each year. Only 54% of residents have English as their mother tongue, and 43% are visible minorities (2001 Census). Toronto schools serve students from over 170 countries (Kilbride, Anisef, Baichman-Anisef & Khattar, 2000). Waterloo Region is an example of a mid-size urban area (population 450,000) that has become increasingly diverse. It has the fifth highest per capita immigrant population of all urban areas across Canada (2001 Census). Recent Canadian policy suggests that this trend towards increasing cultural diversity will only continue, as “immigration is key to Canada’s future” (Canadian Intergovernmental Conference Secretariat, 2004).

Responding to this rapid cultural transformation has been a pressing concern for human service organizations in Canada (Ochocka & Janzen, under review), including those in Toronto (Janzen, 1995) and Waterloo Region (Janzen & Ochocka, 2003). There is still a lack of consensus as to how human services in general (Fleras & Kunz, 2001), and mental health services in particular (Campinha-Bacote, 2002; Harley, Jolivette, McCormick & Tice, 2002; Taylor, 1999), can be inclusive of and responsive to cultural diversity in officially multicultural Canada.

In the 1970s a culture-blind approach was adopted that treated service users the same regardless of their differences. Soon after, a theoretical framework called cultural sensitivity emerged. It emphasized the need for practitioners to be at least minimally aware of cultural differences. More recently, an approach known as cultural competence suggests a need for practitioners to have a more extensive knowledge of cultural issues and skills in tailoring services for specific cultural groups (Betancourt, Green & Carrillo, 2002; Maiter, 2003).

Cultural competence can be conceptualized as a continuum with two extremes. On one end, the cultural literacy model emphasizes in-depth knowledge and expertise about a specific culture. The experiential-phenomenological model, at the other end, encourages service providers not to presume expertise about other cultures which themselves are constantly changing, but to explore their own cultural backgrounds and assumptions (Al-Krenawi & Graham, 2003).

In addition to these culture-oriented models, a number of power-oriented models have guided social and health practice (Almanzor, 1998; Razack, 1999; Strawbridge, 1994). An anti-oppressive framework builds on anti-racist models by being aware not only of “whiteness” as a social privilege, but also of the privilege inherent in other forms of identity, including gender and socioeconomic class. This framework implies that an effective intervention requires that members of socially privileged groups acknowledge the systematic basis of their advantage (“power”) and actively work against these structured inequalities.

The field of community mental health is still grappling with its response to cultural diversity. While there is a growing body of evidence about the many different ways that various social factors determine health (Dunn & Dyck, 2000; Weerasingthe & Williams, 2003), culture is often lacking in this discussion (Baker, 2002) and only very recently has been recognized as a determinant of health (Health Canada, 2004). Indeed, community mental health has identified cultural diversity as a neglected value that currently deserves greater attention (CMHA National, 1998; Prilleltensky & Nelson, 1997).

Western-trained service providers and program planners often do not understand the culturally-specific meanings and customs attached to mental health and mental illness (James & Prilleltensky, 2003; Kim, Brenner, Liang & Asay 2003; Miranda & Fraser, 2002; Pines, Zaidman, Wang, Chengbing & Ping, 2003). Additional barriers deter people from diverse cultural backgrounds from seeking mental health services, including costly services, discrimination, stereotypical attitudes, covert or subtle racism (Hines-Martin et. al., 2003; Kirmayer et.al, 2003; Kirmayer, et. al., 1996), and the pervasive stigma with regards to mental illness in North America (Health Canada 2002). As a consequence, many ethno-cultural groups lack access to appropriate community mental health services (Beiser, 1999; Canadian Task Force, 1988; Peters, 1993) or receive inadequate diagnosis and treatment (Allison, Echemendia, Crawford & Robinson, 1996). The popular media has identified this important social issue, pointing out how culturally inadequate existing mental health services are, negatively impacting on individuals and society (Toronto Star, April 30, 2004).

In order to overcome these shortcomings, community mental health could draw on theory and practice from other human service fields. While discussing this theory and practice, it became clear to the CURA partners that there remains an urgent need for mental health services to implement interventions that explicitly emphasize both power and culture. Such a synthesis is seldom attempted (see Fleras & Spoonley, 1999, whose concept of “cultural safety” is one notable exception outside of the mental health field). The notion of cultural empowerment emerged within the CURA partnership as a preliminary theoretical framework for practical strategies. This framework emphasizes knowledge of other cultures (cultural literacy model), practitioners’ awareness of their own cultural identities and the constantly changing cultural identities of others (experiential-phenomenological model), as well as practitioners’ power status (anti-oppressive model). Such a model can be useful for promoting a holistic understanding of mental health as more than the absence of illness, but also subjective well-being, the interactions between individuals and their social environments, and issues of justice and equality (Epp, 1988).

The proposed shift to a cultural empowerment model fits well with broader shifts in community mental health practice that are leading to an increased emphasis on empowerment, community participation and inclusion, and access to valued resources (Nelson, Lord & Ochocka, 2001a). Service alternatives such as self-help, peer support, empowerment-oriented support coordination, and supported housing and employment are practical examples of this emerging paradigm (Carling, 1995; Ochocka, Nelson & Lord, 1999). This new paradigm argues that the power held by traditional mental health practitioners should be shared with consumers. Additionally, it emphasizes the importance of the community context—the responsibility for recovery does not rest solely on the mental health system but also on external circumstances, including supportive communities (Ochocka, Nelson & Janzen, in press; Jacobson & Greenley, 2001). Mental health supports operating within this new paradigm are effective for both individuals and organizations (Nelson, Lord & Ochocka 2001b).

Developing mental health strategies that are effective for all Canadians, regardless of their cultural backgrounds, requires an analysis of both power and culture. While emerging community mental health practice in Canada is working to minimize power differentials between practitioners and consumers, an equally empowering analysis of culture has not emerged. Present practice typically views cultural diversity as a reality needing to be neutralized or as a challenge to be overcome (e.g., Dumas, Rollock, Prinz, Hops & Blechman, 1999; Phillips, Barrio & Brekke, 2001). Instead, culture could be seen as a strength through the engagement of diverse cultural communities in creating and shaping practice in Canada. Such a view implies a commitment to cultural understanding that may challenge existing approaches to service delivery. It may also mean that practitioners need to reflect on their own cultural assumptions as one of many in multicultural Canada. In short, community mental health practice needs to take culture seriously.