Improving language awareness in mental health care by engaging clinicians of language diverse patients

Background: Despite the diverse linguistic profiles of patients at inner city hospitals, language barrier between patients and clinical staff remains neglected. Reasons may include lack of awareness of language barrier by clinicians and silencing of barriers by organizational practices and management priorities. From prior research, inpatient psychiatry nurses and medical students are least likely to seek the help of interpreters when faced with patients that don’t speak English or French. Reasons for these practice patterns are unknown.

Objectives: Developing previous work, this study aims to clarify the quality of language barriers in clinical settings, focusing especially, but not uniquely, on the work of nurses and medical students, to (1) document clinician awareness of language barriers in their patients; (2) explore how awareness of language barriers can be enhanced professionally and institutionally; (3) evaluate the discourses reinforcing language barrier in clinical practice; and (4) assess whether promoting awareness of language barrier results in a measurable increase in documentation of language dynamics in patient charts and a corresponding increase in clinician satisfaction working with language diverse patients in clinical mental health settings.

Hypotheses: We hypothesize that after focus groups on language barrier over one year on psychiatric services, measurements at Time 1 compared to Time 2 will show (1) a statistically significant increase of clinician awareness of language barriers as measured by mentions of language issues in patient charts and (2) greater clinical satisfaction working with language diverse patients.

Research Methodology and Study Population: The study is divided into two phases, each of one-year duration. Phase 1 will consist of Time 1 ratings during the first year of mentions of language issues in 250 hospital charts of patients with diverse mother languages. A baseline clinician satisfaction survey of working with language diverse patients will be administered to 50 clinicians. After these ratings have been completed, a series of focus groups will be conducted in the last six months of year 1 with clinicians and hospital managers to explore experiences, perspectives and suggestions to improve clinical communication. Phase 2 will consist of follow up focus groups during the first six months of the second year to investigate whether clinician awareness of language barriers has affected individual and team practice i.e. to determine if any change has taken place. After the focus groups are complete, Time 2 ratings of mentions of language issues in 250 patient charts will be conducted, and a follow up clinician satisfaction survey of the same 50 clinicians will be administered, both as in Phase 1.

Data Analysis: Descriptive statistics will be calculated for each study variable. Measures that are scored dimensionally (i.e., clinician satisfaction ratings) will be assessed using Analysis of Variance (ANOVA). Measures that are scored categorically (i.e., language mentioned in chart yes/no) will be assessed using standard Chi-Square tests. Where power considerations allow, analyses will control for confounders that show influence on the pattern of results. Potential confounders include clinician type, clinician experience (years), language ability of patients and clinicians, and duration of time of patients in Québec. Focus groups will be audiotaped and transcribed, then analyzed using the qualitative software MAXQDA for constant emerging themes. This will provide a comprehensive understanding of the construct of language awareness and its associated elements in clinical mental health settings.

Relevance: Linguistic diversity is a fact in clinical care settings. This study will help to bridge the gap between patients who are linguistically diverse and their clinicians’ lack of awareness of linguistic diversity and how it may compromise quality of care.

Clinical Measurement of Verbal Language Proficiency in Patients Referred to a Cultural Consultation Service (CCS)

Background: The CCS of the Jewish General Hospital has been evaluating the mental health of immigrants and refugees since 1999. As may be expected, CCS patients from linguistically diverse backgrounds need interpreter services, but how clinical decisions are made to assign interpreters to a given patient are unknown. Furthermore, there are no clinical language proficiency tools available for use in health care settings. Health care literacy tools exist, but before they can be administered to patients of diverse backgrounds, basic verbal language proficiency in English must first be evaluated.

Objectives: Using a retrospective sample of CCS referrals, this study will demonstrate that clinicians overestimate language proficiency in linguistically diverse patients. Then, a simple tool to measure verbal language proficiency, which can be administered quickly and efficiently in clinical settings, will be piloted on a prospective sample of CCS referrals to address this problem.

Hypotheses: 1) The language proficiency of patients will be overestimated by referring clinicians compared to CCS clinicians; 2) The extent to which referring clinicians differ on their estimation of patients’ language proficiency will depend on several variables, including type of referring clinician and institution, patient age (older versus younger), status in Canada (refugee versus immigrant) and level of formal education; 3) The pilot language proficiency questionnaire will, on average, take less than 10 minutes per patient (clinical utility, feasibility) and will be completed by more than 80% of the approached patients who give their consent to participate in the project (clinical acceptability).

Research Methodology and Study Population: Step 1: Retrospective language data on 150 CCS referrals (over approximately five years, 2013-2017) whose mother language is other than English will be gathered by a research assistant from patient charts. Step 2: Prospective language data on approximately 50 CCS referrals (over one year, 2018-19, with anticipated increasing referral rates due to the recent influx of refugees) whose mother language is other than English will be gathered by a research assistant as per Step 1 above. In addition to comparisons of rated language proficiency between referring clinicians and the CCS clinicians, a participant observer will note the dynamics of language use during the consultation: predominant language spoken, language preferences, and how interpreters negotiate clinical communication. Step 3: Based on input from data gathered during Steps 1&2, a pilot language proficiency questionnaire, clinician-rated, brief (less than 10 minutes), and focusing on verbal language, will be drafted by the CCS researchers and administered prior to cultural consultations by a research assistant to 25 CCS referrals (over six months in 2018-19) to estimate feasibility, clinical utility and acceptability of the instrument.

Data Analysis: Descriptive statistics will be calculated for each demographic and study variable. Analysis of Variance (ANOVA) will be used to determine group differences on estimation of language proficiency. Where power considerations allow, variables from Hypothesis 2 that may influence the pattern of results will be analyzed. Measures that are scored categorically (i.e., patient’s need of an interpreter, yes/no) will be assessed using Chi-Square tests. Thematic analysis of qualitative data, gathered from participant observation, will be used to inform the development of the language proficiency questionnaire and to comment on its feasibility, clinical utility and acceptability in preparation for formal empirical testing.

Relevance: Language barriers are linked to poor mental health outcomes that are preventable if clinicians recognize which patients need interpreter services and plan ahead to provide them. A clinical tool to determine basic verbal language proficiency in English, the first of its kind, would make such interventions possible.

Linguistically- and Culturally-Sensitive Psychotherapy: Improving Communications to Improve Outcomes

Context: Linguistic mismatch can lead to communication problems that interfere with psychological treatments for mental health problems. Cultural misunderstandings can exacerbate these problems. Past research funded by Dialogue McGill has identified ways in which psychotherapists can effectively intervene to overcome linguistic and cultural barriers. The current research proposes to directly evaluate these interventions.

Main Objectives: We will: (1) carry out a systematic review of psychotherapy effectiveness in cross-linguistic and cross-cultural settings; use (2) use qualitative inquiry to study linguistic/cultural misunderstandings between clients and their therapists; and (3) use quantitative techniques to study the impact of interventions designed to mitigate these misunderstandings.

Research Procedures: Participants will be 12 anxiety and/or depression patients from a migrant and/or minority background, all of whom speak English as a second language and prefer English as their first official language. Half will be in a situation of language match with their therapist, and half will have a mismatch, in terms of preferred official language.

Data Analysis:  Qualitative inquiry will give us a close reading on best practices when working with linguistic and cultural diversity. Quantitative modeling will allow us to study the impact of change over time through daily self-report assessments. Some models will include participants from previous Dialogue McGill-funded projects, enhancing statistical power.

Potential Contributions: We anticipate this project will improve mental health care for English-speaking patients in Quebec, as well as improving training of mental health professionals. Results will be relevant to other settings characterized by linguistic and cultural complexity.

Linguistically- and Culturally-Sensitive Psychotherapy: Training and Retaining Migrant & Minority Therapists

Mental health care in multicultural communities is enhanced when local therapists represent the population and when these therapists are trained in linguistically- and culturally-sensitive psychotherapy. Unfortunately, many trainees do not feel well-prepared for diversity and migrants/minorities face barriers to building a career in Québec.

We will: (1) use qualitative inquiry to study perceived training deficits and career barriers in psychologists trained at anglophone institutions; (2) use quantitative techniques to establish a consensus model of the changes needed to retain multicultural expertise in Québec. 

Participants will be 40 clinical psychology trainees and 40 licensed clinical psychologists. This project will use a cultural consensus design, a mixed methods approach with four sequential steps: (1) qualitative interviews (in this case, analysis of previously collected interviews); (2) free listing responses to open-ended questions; (3) sorting the most common responses while thinking aloud; and (4) survey design based on the consensual sorts.

The qualitative interview and think-aloud transcripts will be studied using qualitative inquiry, specifically thematic analysis. The free listing, sorting, and survey components will be studied using quantitative analysis; frequency analysis, multidimensional scaling, and cultural-consensus analysis, respectively.

We anticipate this project will improve training of mental health professionals and will yield steps to boost retention of migrant/minority psychologists in Québec. We will develop recommendations for the two anglophone training programs, and for the professional order. Our results will be relevant to other cultural settings characterized by linguistic and cultural complexity.

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Outputs:

• Zhao, Y., Segalowitz, N., Voloshyn, A., Chamoux, E., & Ryder, A. G. (2021). Language Barriers to Healthcare for Linguistic Minorities: The Case of Second Language-specific Health Communication Anxiety. Health communication, 36(3), 334–346. https://doi.org/10.1080/10410236.2019.1692488

• Ryder, A. G., Doucerain, M. M., Dere, J., Jurick, T., Zhou, B., & Zhou, X. (2021). On dynamic contexts and unstable categories: Steps towards a cultural-clinical psychology. In M. Gelfand, C.-Y. Chiu, & Y.-Y. Hong (Eds), Advances in culture and psychology, volume 8 (pp. 195-245). OUP.

• Voloshyn, A., Dussault, È., Segalowitz, N., Ryder, A. G. (2022, September). A qualitative study of clinical psychologists’ reflections on their work with linguistically- and culturally-diverse clients [Paper session]. Presentation at the 6th World Congress of the World Association of Cultural Psychiatry, Rotterdam, Netherlands.

Linguistically- and Culturally-Sensitive Psychotherapy: Improving Communication to Improve Outcomes

Context: Linguistic mismatch can lead to communication problems that interfere with psychological treatments for mental health problems—not least, because these are linguistic interventions. Cultural misunderstandings can exacerbate these problems. Yet there ways in which psychotherapists can engage in positive ways with linguistic and cultural diversity. Studying how this is best done is particularly relevant to the Quebec situation.

Main Objectives: We will: (1) use quantitative techniques to study the impact of linguistically- and culturally-sensitive therapy on outcomes; and (2) use qualitative inquiry to study the conversations that unfold between clients and their therapists.

Research Procedures: Participants will be 12 anxiety and/or depression patients from a migrant and/or minority background, all bilingual but half who prefer English as their first official language, half who prefer French. Within each subgroup, half will be in a situation of language match with their therapist, half mismatch, in terms of their preferred language.

Data Analysis: Quantitative modeling will allow us to study the impact of change over time through daily self-report assessments. We will be able to see how specific therapeutic interventions benefit specific patients. Qualitative inquiry will give us a close reading on what works—and what does not work—when working with linguistic and cultural diversity.

Potential Contributions: We anticipate this project will improve mental health care for English-speaking patients in Quebec suffering from mental health problems, as well as improving training of mental health professionals. Our results will be relevant to other cultural settings characterized by linguistic and cultural complexity.

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Outputs:

• Zhao, Y., Segalowitz, N., Voloshyn, A., Chamoux, E., & Ryder, A. G. (2021). Language Barriers to Healthcare for Linguistic Minorities: The Case of Second Language-specific Health Communication Anxiety. Health communication, 36(3), 334–346. https://doi.org/10.1080/10410236.2019.1692488

• Ryder, A. G., Doucerain, M. M., Zhou, B., Dere, J., Jurcik, T., & Zhou, X. (2021). On dynamic contexts and unstable categories: Steps toward a cultural-clinical psychology. In M. J. Gelfand, C.-y. Chiu, & Y.-y. Hong (Eds.), Handbook of advances in culture and psychology (pp. 195–243). Oxford University Press. https://doi.org/10.1093/oso/9780190079741.003.0005

• De Oliveira Jr., O., Hammami, S., Quadrio, J., & Ryder, A. G. (2022, May). Creating a front-line transcultural mental health clinic for Montreal-Nord youth. Poster presented at the 2022 Summer Institute for School Psychology, Montréal, QC.

• Ryder, A. G., Quadrio, J., Stora, L., Taing, J., Yampolsky, M., Tao, D., & Segalowitz, N. (2022, May). La culture, la langue et la santé mentale: La « Acculturation Toolbox » pour les chercheurs et les cliniciens. Paper presented at the 44th Annual Congress of the SQRP, Saint-Sauveur, QC.

• Voloshyn, A., Segalowitz, N., Zhao, Y., Ryder, A. G. (2021, July). Linguistic minorities and access to mental healthcare: The case of second language health communication anxiety. Paper presented at the 25th conference of the IACCP, Olomouc, Czechia.

Linguistically- and Culturally-Sensitive Psychotherapy: Evaluating an Approach to Assessment and Treatment

The Centre for Clinical Research in Health (CCRH) successfully established a university- funded state-of-the-art research clinic at Concordia University (of which the principal investigator is co-founding member). The clinic is launching an evidence-based, culturally-sensitive psychotherapy program for migrants with anxiety and/or depression. This larger project provides investigators with a valuable opportunity to evaluate the effectiveness of language-sensitive mental health interventions in a real-life clinical setting.

It is therefore proposed to: (1) Integrate research tools (developed with previous Dialogue McGill funding) into the assessment battery completed by all clients completing the treatment protocol used with migrant clients at CCRH. (2) Use qualitative techniques to study video-recordings and transcripts of actual clinical sessions to study the consequences of language discordance on effective communication and treatment. (3) Use quantitative analysis techniques to test whether potential problems identified by the assessment battery are linked to problematic features of actual clinical interactions. Hypotheses are: H1: Indices related to better functioning in a given language will predict fewer in-session communication difficulties when the treatment is conducted in that language. H2: Fewer in-session communication difficulties will predict more rapid symptom improvement.

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Outputs:

1. Unknown. (2020, May). Cultural scripts for normalcy and deviancy: A mixed-methods approach to understanding mental illness in new contexts [Presentation]. Interacting Minds Center, Aarhus, Denmark

2. Unknown. (2019, November). Linguistically- and Culturally-Sensitive Psychotherapy: A Proposal [Presentation]. Centre for Clinical Research in Health, Montreal, Quebec.

Communication Networks of Linguistic Minorities: Who Talks to Whom About Health?

There is a considerable literature documenting the help-seeking pathways of patients. The early stages usually involve considerable negotiation within a person’s existing social network before outside help is sought. The team has previously developed a social network measure designed to assess linguistic characteristics of social networks (Ryder & Segalowitz, funded by Dialogue McGill) as well as a measure of second language health communication anxiety (Segalowitz & Ryder, funded by Dialogue McGill). The overarching goal of this project is to finalize the adaptation of these measures to Multilanguage settings, establish their psychometric properties, and explore the interrelations of these instruments in Francophone and Anglophone community samples. To this end the project has proposes the following objectives: (1) Adapt the acculturation battery for use in multilingual settings. (2) Translate the adapted acculturation battery into French (the other measures have already been translated). (3) Implement an online system to deliver the entire set of measures in either language. (4) Evaluate the overall set of measures in Francophone and Anglophone community samples.

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Outputs:

1. Zhao, Y., Segalowitz, N., Voloshyn, A., Chamoux, E., & Ryder, A. G. (2021). Language Barriers to Healthcare for Linguistic Minorities: The Case of Second Language-specific Health Communication Anxiety. Health communication, 36(3), 334–346. https://doi.org/10.1080/10410236.2019.1692488

2. Ryder, A. G., Doucerain, M. M., Dere, J., Jurick, T., Zhou, B., & Zhou, X. (in press). From acculturation and psychopathology to cultural-clinical psychology. For M. Gelfand, C.-Y. Chiu, & Y.-Y. Hong (Eds), Advances in culture and psychology (vol. 8). Oxford, U.K.: Oxford University Press.

3. Chang, J., Pak, S., Doucerain, M. M., & Ryder, A. G. (2019, January). Validation of the AIM as a well-being and acculturation measurement tool [Poster presentation]. Sixth Annual Conference of the Centre for Clinical Research in Health, Montreal, QC, Canada

4. Tao, D., Doucerain, M. M., Segalowitz N., & Ryder, A. G. (2018, October). Social network and mental health help-seeking attitudes: The case of Chinese migrants in Montreal [Poster presentation]. 5th International Convention of the World Association of Cultural Psychiatry, New York, NY, USA

5. Tao, D., Doucerain, M. M., Segalowtiz N., & Ryder, A.G. (2018, July). What’s the relationship between one’s social network and mental health help-seeking attitudes? The case of Chinese migrants in Montreal. Paper presented at the 24th International Congress of International Association of Cross-Cultural Psychology, Guelph, ON, Canada

Improving language awareness in mental health care by engaging clinicians of language diverse patients

Despite the diverse linguistic profiles of patients at inner city hospitals, language barrier between patients and clinical staff remains neglected. Reasons may include lack of awareness of language barrier by clinicians and silencing of barriers by organizational practices and management priorities. From prior research, inpatient psychiatry nurses and medical students are least likely to seek the help of interpreters when faced with patients that don’t speak English or French. Reasons for these practice patterns are unknown.

Developing previous work, this study aims to clarify the quality of language barriers in clinical settings, focusing especially, but not uniquely, on the work of nurses and medical students, to (1) document clinician awareness of language barriers in their patients; (2) explore how awareness of language barriers can be enhanced professionally and institutionally; (3) evaluate the discourses reinforcing language barrier in clinical practice; and (4) assess whether promoting awareness of language barrier results in a measurable increase in documentation of language dynamics in patient charts and a corresponding increase in clinician satisfaction working with language diverse patients in clinical mental health settings. Investigators hypothesize that after focus groups on language barrier over one year on psychiatric services, measurements at Time 1 compared to Time 2 will show (1) a statistically significant increase of clinician awareness of language barriers as measured by mentions of language issues in patient charts and (2) greater clinical satisfaction working with language diverse patients.

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Outcomes were curtailed by the COVID-19 pandemic.

Clinical Measurement of Verbal Language Proficiency in Patients Referred to a Cultural Consultation Service (CCS).

The Cultural Consultation Service of the Jewish General Hospital has been evaluating the mental health of immigrants and refugees since 1999. As may be expected, CCS patients from linguistically diverse backgrounds need interpreter services, but how clinical decisions are made to assign interpreters to a given patient are unknown. Furthermore, there are no clinical language proficiency tools available for use in health care settings. Health care literacy tools exist, but before they can be administered to patients of diverse backgrounds, basic verbal language proficiency in English must first be evaluated. Using a retrospective sample of CCS referrals, this study will demonstrate that clinicians overestimate language proficiency in linguistically diverse patients. Then, a simple tool to measure verbal language proficiency, which can be administered quickly and efficiently in clinical settings, will be piloted on a prospective sample of CCS referrals to address this problem.