The accessibility and adequacy of youth mental health (YMH) services are ongoing concerns, as the number of youths with mental health issues who actually receive services is alarmingly low (Leckman and Leventhal
; McGorry et al.
). In our globalized societies, this is an even greater issue for migrant (immigrant or refugee) families not familiar with the health system in their new host country. Such families and their youth are known to underutilize mental health services and to face barriers to accessing these services (Ellis et al.
; Nadeau and Measham
; Ter Kuile et al.
). In addition, little attention has been paid to service provision in migrant and multiethnic neighborhoods, where the acceptability of mental health services may be a more complex issue and call for greater service adaptation (Nadeau and Measham
; Pina and Gonzales
). Cultural representations and recent migratory experiences influence the expression of mental health issues and the ways families seek help (Rousseau et al.
). The way mental health suffering is transformed into symptoms is framed by culture (Obeyesekere
) and socially sanctioned idioms of distress (Rechtman
). Explanatory models of mental health issues vary around the world, and migrants’ frames of reference regarding the reasons for the appearance of symptoms and the actions needed/expected to address such symptoms may differ from those held by their health care providers (Kleinman
). Moreover, migrants also go through a “cultural transition process” (Pumariega et al.
) as they interact with the host society, by which their representations of illness and treatment are transformed.
Collaborative care between mental health specialists and primary care clinicians is aimed at providing avenues for improving access to mental health care. Emerging research supports the advantages offered by this model in addressing barriers to care for vulnerable migrant youth (Rousseau et al.
). Collaborative care is a patient-centered model of services in which the patient is seen as a partner in decision-making; this model brings together all the professionals involved in care to elaborate a care plan and implement it (Kates et al.
). Collaborative models of services in YMH are complex, requiring a comprehensive intervention paradigm with multidisciplinary care and intersectoral service collaboration. Treatment needs vary according to the child’s development, clinical presentation, family issues, as well as co-contributing community and school factors in addition to the larger socio-cultural context. While specific models have been developed to operationalize collaborative care in YMH (Aupont et al.
; Kolko et al.
; Lipton and Donsky
; Nadeau et al.
), collaborative models still lack robust assessment to ensure optimal adaptation to YMH, a challenge that must be addressed through solid research-practice partnerships (Garland and Brookman-Frazee
In addition to the dearth of studies on the best models of care for YMH services (Tylee et al.
), especially for migrant families, there is little understanding of the patients’ perspectives (Gampetro et al.
; McGuirk and Button
) likely to inform these models, despite a movement toward patient-centered care and growing evidence that patient preference regarding treatment increases adherence and promotes better outcomes (McHugh et al.
). A more nuanced perspective could be achieved through the triangulation of clinician and family voices, which would be vital to understanding perceived barriers to care (Kazdin et al.
In order to further the field of YMH collaborative care models, the current study draws on underresearched elements important to consider when developing such models, especially for migrant youth. This project was designed in Montreal, Canada, to explore youth, parent and clinician perspectives on YMH services in a collaborative care model. The study took place in a primary-care, community-based health and social service center (CSSS) (Montréal, Canada) that serves a multiethnic population and has three local services centers (known as CLSCs). These centers have a tradition of offering proximity services in multiple locations (such as the CLSCs themselves, schools, or patients’ homes). Since 2007, YMH services have been offered as part of a collaborative care model involving multidisciplinary teams and on-site child psychiatrists acting as consultants and providing support to CSSS youth teams (in an integrated co-location model). This model entails the involvement of child psychiatrists in team meetings, as well as in formal and informal case discussions apart from consultations with patients at which main case workers are present. This exploratory study was aimed at developing a better understanding of the quality of care for migrant families including the process of accessing care and receiving collaborative YMH services as well as the efficiency of such services and the degree of satisfaction with them. The study employed a primarily qualitative research design, also incorporating the testing of quantitative questionnaires to be used in a wider study currently under way. The present article focuses on the project’s qualitative results. The study was the first step in a research program on collaborative YMH care, and provided an opportunity to document important themes and patterns in care trajectories which could potentially inform services and further research. A “follow the thread” research process was adopted to ensure these early results inform subsequent research steps (O’Cathain et al.
Our pilot study offers avenues to better understand the important challenges in offering appropriate mental health care to vulnerable families (Nadeau et al.
). Results support the importance of collecting multiple informant perspectives when addressing the quality of mental health care. Interesting similarities and contrasts can be identified when looking at the perspectives of different study stakeholders. Our results based on the thematic analysis by actor category suggest that migrant youth and their parents are particularly concerned with YMH care settings and how comfortable they are with such venues, as well as with the integration of family issues into treatment. Clinicians emphasize the collaborative aspect of care while focusing on its systemic context. They address the importance of interprofessional and institutional support, while underscoring the need to understand family vulnerability and any sociocultural factors influencing care. The triad results provide further support for the importance of the care setting while adding emerging themes that can be viewed as part of the overarching framework of care (exploring differences between explanatory models held by family and clinicians, addressing cultural difference in values, and observing the evolution of trust within the therapeutic process). Based on these results, four themes emerged that should be further researched as potential elements of an optimal care setting for collaborative YMH services for migrant families: (1) establishing an equilibrium between communication, collaboration and privacy/confidentiality, (2) special attention to ensuring the continuity of care and the creation of a welcoming environment where trusting relationships can develop, (3) the inclusion of family intervention, and (4) the provision of collaborative decision-making pathways to care, addressing interprofessional and interinstitutional collaboration as well as cultural differences in explanatory models and values.
Adapted communication appeared in our results to be one of the crucial ingredients in pathways to care. A judicious use of communication between professionals is a necessity in models of collaborative care as partnership implies the sharing of information and discussion of clinical situations. However, there is little talk in collaborative care of the benefits of discussing interprofessional communication—even when framed by confidentiality and privacy protocols—with families to preserve the latter’s sense of comfort. This issue seems particularly salient in YMH, where clinical situations often involve a few, if not a wide range of professionals, as well as challenges regarding privacy. Our results suggest that families are particularly sensitive to this issue, and that there is a benefit of communication modalities to be adapted to each clinical situation to foster a sense of optimal collaboration, safety and confidentiality. Further research could explore how an acknowledged consensus around communication regarding the content of the shared information and the terminology to be used when describing the youth’s issues could be helpful in establishing the right balance between knowledge-sharing and the protection of privacy, and how this consensus could further benefit from being reviewed over time, as preoccupations of families vary throughout the care process. It also seems important that schools, which are key partners, be given special consideration: while schools represent an open setting that may offer a great deal of support, they also constitute an environment in which young people’s stories or difficulties may be more exposed. Although schools have confidentiality protocols with clear rules around accessibility to privileged information concerning children, students and their families may fear a breach in confidentiality and indiscretion, as our results suggest. If mental health services are offered directly on the school premises, it adds the benefit of proximity. However, offering services in schools, especially high schools, may make it difficult to hide the fact that a youth is seeing a psychologist or any other professional. Trust in the intervention provided builds on belief in the confidentiality of the system and familiarity with the system. For migrant families who are unfamiliar with the host society’s different institutions and who may have experienced marginalization or discrimination, the building of trust may require extra steps. Our results tend to support that providing a safe clinical environment also means helping youth and parents learn about and get their bearings within the unfamiliar care system.
Our results also suggest benefits to building a sense of continuity of services that can be materialized in efforts to keep a family with the same clinician or same team, and to facilitate liaisons between institutions. They further tend to show that it can be challenging for clinicians to develop a trusting relationship and alliance with migrant youth and families who have already experienced a number of ruptures in their migratory process. While this favors a certain stability of clinicians within teams, the reality of collaborative care often means that patients circulate between services and institutions. A meta-summary by Haggerty et al. (
) shows that the experience of continuity of care when patients see multiple clinicians contributes to patient security and confidence. According to the authors, this translates into the patient being supported through transitions as well as having one trusted clinician who views the patient as a partner while helping the patient navigate the patient’s care pathway in the health care system. As illustrated by our results, it should be further explored how, in front of such mobility in the health care system, the creation of a safe space could be established in YMH in collaboration with all involved institutions. The exploration of ways to foster a sense of continuity and safety appears particularly important when working with migrant families for whom the host society’s health system may feel quite unfamiliar. Within such a study the aforementioned optimized communication could be one of the ingredients considered in fostering continuity of care for migrant youth and their families.
Other potential ingredients of a safe care environment pertain to the creation of a welcoming environment. Youth in particular stressed how details affecting their degree of comfort with therapy rooms and the sense of welcome they experienced from the people with whom they first came into contact in the system of care influenced how they felt about services overall. Further research could examine the potential benefit in terms of accessibility of care for community-based health institutions to place greater importance on ensuring a welcoming therapy setting (people, space and timeframe) for youth and families. A safe care environment ties in with the concept of cultural safety, in the sense of a culturally adequate and respectful setting. The concept of cultural safety was developed in New Zealand to describe how accessibility to health services for Indigenous people meant an environment where they would feel welcomed and not discriminated against (Smye and Brown
). The concept is echoed in the literature devoted to migrants (Nadeau et al.
), and the current study’s narratives again underscore the positive effect of a safe care environment.
Our results further propose high consensus among families and clinicians regarding the importance of family interventions. Families’ narratives stress the crucial effect of such interventions and the positive impact of clinical spaces in which youths and their parents felt sufficiently at ease to dialog. These narratives place the family relationships at the heart of both the problem and the solution. The results raise questions about models of care that focus mainly on the young person, and in which confidentiality and autonomy (the individual perspective of the youth) issues are put in the forefront while parents’ contributions are left in the background. Some such models involve parents only when the youth is at risk. Although the narratives of our research participants highlight the importance of privacy and individual intervention, they also suggest the important benefits of models that address communication between youth and parents within the clinical space in situations involving externalized behavioral issues or internalized symptoms. They underscore the complementarity of interventions that address symptoms (psychoeducational strategies) with those that target family dynamics. Clinical outcomes are often measured in terms of change in symptomatology (e.g., as measured with a grid such as a depressive inventory) and impairment. Our results suggest the importance of improvement in family communication (with work on cohesion and conflict), which in fact may be both an important outcome and mediating factor to measure. Whereas the literature on systemic and family therapy has regularly stressed this aspect, the principal current discourse on mental health strategies often emphasizes medical and individual therapies instead (Dunnachie
). Our results echo other research suggesting that the association between symptoms in adolescents and family functioning is a circular process wherein each factor affects the other over time (Brière et al.
Lastly, developing a clear and collaborative decision-making pathway was important to participating clinicians offering YMH services to migrant patients and their families. In YMH interinstitutional collaborative care, service effectiveness depends on productive communication channels (Chang et al.
), and on the capacity of partners to complement one another in an optimal way to arrive at the best decisions regarding treatment. Our results suggest that these elements of partnership concern both institutions and individuals within the institutions, in terms of familiarizing themselves with one another’s roles, adopting a collaborative attitude characterized by confidence in one another. The results also propose the importance of providing space for clinical discussions. Previous research has shown how forums for clinical discussions are instrumental in building collaborative care (Nadeau et al.
). Yet this is an important challenge for health and social services institutions under considerable pressure due to budget cuts.
Our results further suggest that treating families and young people as partners in care to improve access to services and participation in decision-making implies understanding their point of view and being open to taking their explanatory model of the problem into consideration in the dialog around treatment. A study by Ødegård and Bjørkly (
) describes how the fit between the explanatory models of parents and those of clinicians can be an important factor in outcomes. One possible point of divergence between families and clinicians may be over the values to be transmitted to youth. This includes attitudes toward authority, which is a fundamental value and object of negotiation in families when children reach adolescence, and probably even more so when immigration transforms its representations. Our results suggest that, in families struggling to empower themselves when dealing with the mental health system, migrant families face the extra challenge of negotiating this authority from a particularly vulnerable position linked to their unfamiliarity with the system and to the way the system perceives migrants, which is all too often as less capable. Furthermore mental health issues or palpable tensions within the parent–child relationship may produce ambivalence and challenges with respect to the role of partners in care. These results thus propose that making families partners in decision-making involves allowing both parents and youth a form of autonomy and self-agency within the system of care while providing room for generational differences, and supporting them as true partners. Our results also put forward how the youth and parents’ perspectives on decisions and therapy may transform throughout the process of treatment, with some moving from a passive stance to an active one. This suggests that taking into account their perspectives regarding treatment implies interpreting their voices in their proper context, keeping in mind that the presence of mental health issues in families may weaken their ability to reflect optimally on finding a solution. Patient preferences are considered an integral part of evidence-based practice (McHugh et al.
), yet they have to be assessed in a longitudinal manner that acknowledges their potential transformation over time.
This study has limits inherent to pilot studies. The generalizability of our results is restricted by the small sample size and specific research context, by the transversal nature of the data, as well as by the recruitment strategy. A sample of 5 triads and 15 participants provides non-optimal saturation of data. Some of our results are likely to be influenced by the characteristics of the neighborhood and community clinic (including the type of proximity services offered) in which the research was conducted and this limits the capacity to generalize to other contexts. Given the pilot project nature of the study, only transversal data were collected, rather than longitudinal data which could have provided a more nuanced interpretation. Moreover, for ethical reasons, we relied on clinicians to approach families for the study. Clinicians were invited to identify and approach youths who might be potential participants before a member of the research team contacted them to explain the study and invite them to participate. While this offered the ethical advantage of ensuring families and youths would be comfortable with the study, in addition to facilitating the alliance, it also restricted recruitment, resulting in the sample not being fully purposeful. Furthermore, this sample included more externalizing symptoms than internalizing ones, and was comprised mostly of Asian subjects (from South-East Asia and South Asia). While participants seemed representative of migrant youths in the administrative region of the community-based services, further research should look at a more comprehensive sample in terms of symptomatology and ethnic diversity to determine whether the results would then be replicated or transformed. However, while the small sample does not allow for generalization to other contexts, this study on YMH services offers a perspective rarely explored in the literature, taking into account the experience of youths, parents and clinicians, and has provided useful hypotheses for the development of a more substantial research project on YMH services for migrant families that would also benefit from a mixed-method longitudinal design. This type of design would allow examining the hypotheses more rigorously, with both qualitative and quantitative instruments (for example to look at importance of family dynamics through semi-structured interviews as well as through a validated questionnaire). Another limitation is the absence of a comparison group of non-migrant youth. To a certain extent, the results may also reflect preoccupations regarding YMH care shared by non-migrant families. This again underscores the necessity of conducting a larger research project to examine these issues more globally with both migrant and non-migrant subjects.