Reported immigration and medical coercion among immigrants referred to a cultural consultation service

Abstract

Members of visible minorities are commonly targets of social coercion related to immigration and medical measures. Social coercion is associated with poor mental health outcomes and mistrust of medical services. This study will determine if Afro-Canadian immigrants referred to a Cultural Consultation Service (CCS) in Montreal report more or less medical and immigration coercion compared with other ethnic minorities. We reviewed the charts of 729 referrals to the CCS and gathered data on the 401 patients included in the study. Chi-square statistics examined the relation between minority group and self-reported coercion. Binary logistic regression models controlled for standard sociodemographic variables in addition to ethnicity, language barrier, length of stay in Canada since immigration, refugee claimant status, referral source, presence of psychosis in the main diagnosis, and presence of legal history. Patients were diverse and included 105 Afro-Canadians, 40 Latin Americans, 73 Arab and West Asians, 149 South Asians, and 34 East and Southeast Asians. Being Afro-Canadian was significantly and positively associated with medical coercion (p = .02, 95% CI = 1.15-4.57), while being South Asian was negatively and significantly associated with immigration coercion (p = .03, 95% CI = .29–.93). Members of visible minority communities are not equal in their reported experience of social coercion after arriving to Canada. Future research clarifying pathways to mental health care for immigrants and the experience of new Canadians in immigration and health care settings would give needed context to the findings of this study.

Keywords

coercion minority immigration Afro-Canadian South Asian cultural consultation

Introduction

The concept of coercion in psychiatry is a debated topic, especially in the current context of globalization and immigration (Castille, 2011). Coercion in the lives of immigrant patients with mental health problems may take many forms, but two of the most common include coercion in the context of immigration (Steel, 2006; Mares & Jureidini, 2004) and in medical (particularly psychiatric) settings (Busch & Shore, 2000; Rosen & DiGiacomo, 1978; Brown & Tooke, 1992), although the two concepts commonly intersect during an immigrant's trajectory in the country of adoption (Steel, 2006; Rousseau, 2002; Chan, 2005; Thompson, 1998; Sultan & Sullivan, 2001; Steel & Silove, 2001). While the term “immigrant” refers to the foreign born, many immigrants to Canada belong to an additional category called “visible minorities.” This is a broad term that the 2016 Canadian Census defines as “persons, other than Aboriginal peoples, who are non-Caucasian in race or non-white in colour” and consists of the following groups: South Asian, Chinese, Black, Filipino, Latin American, Arab, Southeast Asian, West Asian, Korean, and Japanese (Statistics Canada, 2016: Census of Population; Statistics Canada, 2016: Visible Minority and Population Group Reference Guide) (see Appendix 1 for details, which can be found online with this article). This study will assess the reported rates of immigration and medical coercion in immigrant visible minorities referred to a Cultural Consultation Service in Montreal.

Immigration coercive measures are acts taken by the state towards immigrants and refugees – often in order to discourage asylum seekers from entering and remaining in the country's borders (Steel, 2006) – and include (though not exhaustively) refused refugee claim, threatened or actual deportation, and immigrant detention (Steel, 2006; Mares & Jureidini, 2004; Rousseau, 2002; Chan, 2005). It is well documented that these measures, including immigrant detention, are associated with high rates of psychiatric comorbidity (Thompson, 1998; Sultan & Sullivan, 2001; Steel & Silove, 2001). In Canada, immigration coercion is poorly documented (Chan, 2005). This may be why a comparison of reported coercive immigration measures among immigrants to Canada has never been attempted. In fact, Canadian history has been marked by considerable racial distinction and exclusion, a direct result of discriminatory immigration policies that have only been reversed within the last 50 years (Li, 2003). As recently as 1995, the Federal Government introduced Bill C-44 to allow the deportation, without the right to appeal, of Canadian permanent residents judged by the Minister to represent a danger to the public of Canada (Barnes, 2009). The bill was introduced in the context of two highly publicised crimes in 1994 in which Black immigrants killed White Canadians (Pratt, 2005; Globe and Mail Editorial, 2012). Although statistics about deported asylum seekers from Canada are not available to the public (Chan, 2005), Chan (2005) reviewed the 177 deportation decisions specifically based on criminal conduct by the Appeal Decision of the Immigration and Refugee Board from 1992 to 2002. The countries most represented were Jamaica, Iran, India, Vietnam, Guyana, and Trinidad (Chan, 2005). Although specific numbers were not available for the aforementioned countries or for all deported cases, Table 1 provides the total numbers of documented, foreign born immigrants in Canada from 1951 to 2011 for comparative purposes (Statistics Canada, 2016: 150 years of immigration in Canada). Indeed, deportation to Caribbean countries from Canada was significant and followed a worldwide trend (Eelens, 2005). Unfortunately, more recent data relevant to these issues are not available, indicating the neglected status of the literature on deportation and other acts of immigration coercion in Canada.

Table 1.

Foreign born population in Canada, by selected regions of birth, 1951 to 2011.

Area of interest	1951	1961	1971	1981	1991	2001	2011
Caribbean and Bermuda	4400	12 400	68 100	173 200	232 500	294 100	351 400
Central and South America	3100	0	36 000	106 800	219 400	304 700	442 700
Northern Africa	400	0	28 700	38 700	53 200	93 200	186 700
Sub-Saharan Africa	2400	4000	10 700	63 000	113 000	189 500	305 300
Western Asia and Middle East	6500	0	25 200	63 200	151 100	285 600	456 000
Eastern Asia	30 800	43 500	66 600	195 500	377 200	730 600	962 600
Southeast Asia	800	0	13 100	152 200	312 000	469 100	729 800
Southern Asia	4200	9000	46 300	130 000	228 800	503 900	892 800

Sources: Statistics Canada, censuses of population, 1951 to 2001. National Household Survey, 2011.

Medical coercive measures are interventions by health professionals that lead to a temporary suspension of the patient's individual rights and typically include involuntary hospitalization, forced or intramuscular medication, physical restraint, seclusion, and court-ordered forced (mandatory) treatment (Jarvis, 2002; Kallert, 2011). While these medical acts may be justifiable, even clinically necessary in many cases – such as emergency intramuscular medication for an agitated patient – the fact remains that for many patients, they are perceived as undermining their freedom and dignity (Brown & Tooke, 1992; Fisher, 1992), coercive, and traumatic (Fernando, 1988; Littlewood & Lipsedge, 1997; Sashidharan & Francis, 1999; Sashidharan, 2001; Chakraborty & McKenzie, 2002; Oaks, 2011). Furthermore, these measures – if viewed on a larger population scale – might be applied in an uneven fashion, resulting in certain visible minorities receiving them more often than the White, native-born population in Euro-American countries (Singh, 2007; Davies, 1996; Bhui, 2003). This is not only a clinically important issue, but also a politically charged and ethically contentious matter (Singh, 2007). Indeed, some studies report that members of immigrant visible minorities are more likely to be treated by coercion even after controlling for socioeconomic and diagnostic differences – including diagnoses for psychosis and socio-cultural differences in symptom presentation (Davies, 1996; Bhui, 2003; McKenzie, 2007). Most of the existing literature focuses on Blacks in the United Kingdom (UK) and USA and Latin Americans in the USA (Chiu, 2016), with minimal attention paid to Asian minorities living in Western countries, including Canada (Chiu, 2016). In the UK, for example, Blacks are hospitalised involuntarily in psychiatry up to four times more often than Whites (Pipe, 1991; Commander, 1997; Maden, 1999; Audini & Lelliott, 2002; Ali, 2007; Morgan, 2005; De Wit, 2012). The 2006 National Health Service survey (in the UK) reported that psychiatric inpatients from Black and minority ethnic groups were 19-39% more likely to be admitted involuntarily compared with the general population (McKenzie, 2007). These findings have been replicated in a recent census of psychiatric inpatients in England and Wales (Corrigall & Bhugra, 2010) and in the most recent available literature from 2017 (Ajnakina, 2017; Morgan, 2017). In addition, Black adolescents were more likely to be detained on admission and more likely to be foreign born and have a refugee background (Corrigall & Bhugra, 2010; Tolmac & Holdes, 2004). Similar disparities in mental healthcare have also been documented in the United States, with Blacks having higher rates of psychiatric admission – overall and involuntary – than Whites (Lindsey & Paul, 2004; Snowden & Cheung, 1990; Lawson, 1994), findings that parallel the prison literature (Wolff, 2007). Furthermore, in the literature on chemical restraints, African Americans were given more often intramuscular medication for agitation than Whites (Flaherty & Meagher, 1980; Strakowski, 1995; Bola, 1996), but differences in overall dosing of oral antipsychotic medication have been inconsistent (Gudjonsson, 2000; Gudjonsson, 2004; Hicks, 2004). Various studies in the USA found that African Americans were more likely to receive depot antipsychotics than Whites despite no evidence that African Americans tolerated long-acting injectables better than Whites (Citrome, 1996; Valenstein, 2001; Kuno & Rothbard, 2002; Shi, 2007). Some authors hypothesised that clinicians might perceive African Americans to be less adherent to treatment and more likely to express hostility and suspiciousness than Whites, therefore requiring depot medications more often than other patients (Valenstein, 2001).

Canada is not immune to medical coercion that may occur excessively in members of immigrant minorities. An Ontario study found that non-White patients were disproportionately hospitalised in psychiatric intensive care units (Feinstein & Holloway, 2002). Another study in Montreal found that Afro-Canadian inpatients with psychosis were more likely to have police or ambulance contact prior to hospital admission (Jarvis, 2005), an important finding since visible minority patients historically have viewed police contact as an extension of coercive psychiatric practice (Jarvis, 2002; Jarvis, 2005). A third study reported that, among patients admitted to psychiatry for psychosis, more were of African descent compared to patients from other visible minority and European backgrounds (Jarvis, 2011). Most recently, a study from Toronto found that police or ambulance brought patients of South Asian and East Asian origins, who were detained involuntarily by the Mental Health Act, more often to emergency psychiatric services (Rotenberg, 2017). Yet another Ontario study (Chiu, 2016) found that Chinese and South Asians were involuntarily hospitalised more often than other patients (which included other visible minorities and Caucasians). On the other hand, another recent Ontario study (Archie, 2010) reported that Asians experienced less involuntary hospitalizations than Whites and the other individual ethnic groups, including Blacks. Despite these findings, the use of coercive measures in immigrant visible minorities remains poorly elucidated in Canada (Archie, 2010).

A critical aspect of coercion in any form is the subjective experience of these practices, especially taking into account that patients from visible minorities represent a vulnerable population who commonly endure baseline prejudice and discrimination in the host country (Fernando, 1988; Littlewood & Lipsedge, 1997; Sashidharan & Francis, 1999; Sashidharan, 2001; Chakraborty & McKenzie, 2002; Oaks, 2011). Thus, regardless of the political legality and clinical appropriateness of coercive measures, the perception of such acts by patients represents a critical dimension of coercion that must not be obscured by research, administrative, and clinical agendas. Hence, the subjective component of coercion must be given a voice by gathering data on the nature of coercive events as reported by the patients themselves (Oaks, 2011). This study will do just that by carefully gathering reported coercive events by immigrant visible minority patients referred to a Cultural Consultation Service in Montreal.

Given the ethical and clinical importance of this topic, and the sparse data in the Canadian literature (Chan, 2005; Archie, 2010), this pilot study will compare rates of reported immigration and medical coercion among immigrant and refugee visible minority patients referred to the Cultural Consultation Service (CCS) in Montreal, Quebec, Canada. This study offers a unique perspective because rates of reported coercion will not be compared to a White (Euro-American or Euro-Canadian) reference group as has been the case in most previous studies. Given the existing literature, predominantly from the UK and USA with sparse Canadian data (Chiu, 2016; Archie, 2010), we hypothesise that Afro-Canadian patients referred to the CCS will report more immigration and medical coercion than members of other immigrant visible minorities. This study will conduct a series of novel comparisons: first, reported coercion in immigrant Afro-Canadians compared to all other immigrant visible minority patients; and second, reported coercion in each of the other immigrant visible minority groups in turn compared to all other immigrant visible minority patients. For each ethnic group, Afro-Canadian or other, level of reported coercion will be tested following exactly the same method and procedures.

Methods

Site and setting

The Cultural Consultation Service (CCS) of the Jewish General Hospital in Montreal, Quebec, is a government-funded, specialty psychiatry clinic that clarifies the diagnosis and treatment of immigrants and refugees with mental health problems (Kirmayer, Guzder, & Rousseau, 2013). Most of the patients referred to the CCS are foreign born and 40% are refugees. Three part-time psychiatrists, an intake coordinator, and a network of interpreters and culture brokers staff the CCS. Common referral sources include psychiatrists, family physicians, psychologists, and social workers; referrals are not limited to any geographical zone and come mainly from Montreal and suburbs. The Jewish General Hospital is located in the Côte-des-Neiges district of Montreal, one of the most ethnically diverse neighbourhoods in the province of Quebec. The CCS is a specialised referral center and as such does not reflect the overall immigrant or visible minority population in Montreal, Quebec, or Canada, but presents a unique opportunity to compare the reported experience of immigrants belonging to various immigrant visible minority groups referred for clinical evaluation.

Procedures

The Institutional Review Board of the Jewish General Hospital approved the project (the reference number is CR 13–58). A chart review was conducted for subjects in the CCS database from its inception in 1999 through February 2, 2015. The first author (DQT) gathered data with a form developed for this purpose (available on request). Aside from clinical triage sheets and clinical reports, most CCS charts contained emergency department records, past psychiatric and medical evaluations, hospital discharge notes, immigration documents, and youth protection documents (where applicable); all documents were reviewed in addition to transcripts of clinical case conferences, when available.

Prior to every clinical evaluation, routine sociodemographic information was collected at intake by the CCS coordinator in addition to ethnicity, country of origin, religion, and mother tongue. Language barrier was defined as an inability to communicate in either English or French (also gathered at intake). Visible immigrant minorities were then classified according to the 2006 Canadian Census (Statistics Canada, 2006: Ethnic origin and generation status table; Statistics Canada, 2006: Visible minority groups table) (at the time of data collection, the 2016 Census was not yet available), which provides an official, extensive list of ethnic groups it defines as ‘visible minorities’’ (Appendix 1 provides details of the procedure). This procedure yielded five visible minority groups: 1) Afro-Canadian, or Black (e.g. Sub-Saharan Africa, Caribbean); 2) Latin American; 3) Arab or West Asian (North Africa, Lebanon, Iran, Afghanistan, etc.); 4) South Asian (India, Pakistan, Bangladesh, etc.); and 5) East or Southeast Asian (China, Japan, Vietnam, Indonesia, etc.).

Figure 1 details case selection for this study. We only included cases where an actual patient evaluation took place; patient no-shows and case discussions were excluded. Of the 507/729 cases initially retained, we excluded the 38 patients born in Canada (which included 19 Aboriginals) since we wanted to focus on first-generation immigrants (i.e. not born in Canada), which includes refugees. Next, we excluded minors (30), couple and family evaluations (21), and patients whose age was not noted (2), as well as Europeans (14) and Americans (1), in order to focus exclusively on immigrant visible minorities as defined by the 2006 Canadian Census (Statistics Canada, 2006: Visible minority groups table). This left 401 cases for analysis, with 105 Afro-Canadians (Blacks), 40 Latin Americans, 73 Arab and West Asians, 149 South Asians, and 34 East and Southeast Asians.

Figure 1.

Case selection from N = 729 patient charts.

Clinical information included the diagnosis by the referral source prior to the CCS evaluation, type of referring clinician, and the diagnosis after the CCS evaluation. We noted if psychosis was present in the initial referral diagnosis and final CCS diagnosis. The patient's reported legal history was explored for criminal charges, convictions, incarcerations, and other measures such as probation. Immigrant detention was classified as a coercive immigration measure and thus not counted in legal history; likewise, police brutality in the country of origin was not counted in legal history unless it occurred as a consequence of bona fide criminal activity on the part of the patient.

Data on medical and immigration coercive measures were gathered from the database. By reading through the charts, the authors noted all reported immigration and medical coercive events (Appendix 2 details all the categories of reported events in the CCS medical records). The reported coercive measures, in this study, referred to any act of coercion emerging from direct patient interviews and evaluations (which would be noted in the written clinical reports), or coming from supporting documents that may accompany the referral.

Inter-rater reliability was determined for key variables: 1) gender and marital status, 2) final principal CCS diagnosis of psychosis, 3) presence of either immigration or medical coercion, and 4) refused refugee claim in Canada. Data from 20 CCS charts were randomly selected for reliability testing by one research assistant. Kappas were acceptable at κ = 1.0 for gender, κ = 0.87 for marital status, κ = 1.0 for diagnosis of psychosis, κ = 0.89 for presence of either immigration or medical coercion, and κ = 1.0 for refused refugee claim in Canada.

Using IBM SPSS Statistics, Version 20, chi-squared analyses tested differences in the proportion of coercive measures among visible minority groups. Binary logistic regression (forward stepwise method) controlled for standard sociodemographic variables in addition to ethnicity, language barrier, length of stay in Canada since immigration, refugee claimant status, referral source, presence of psychosis in the final CCS diagnosis, and presence of legal history. Due to relatively low numbers in some groups, we used small logistic regression models while controlling for one designated immigrant visible minority category at a time. These models compared reported coercion by each designated group sequentially to the coercion reported by all other groups combined. So, reported coercion by Afro-Canadians (Blacks), for example, was compared to reported coercion by the other groups combined, and then repeated for each group in sequence: Arab or West Asian compared to all others, East or Southeast Asian compared to all others, and so forth.

Results

Table 2 details the immigrant visible minority categories (ethnicities) of the 401 retained cases in addition to select demographic and clinical characteristics. Patients came from 69 countries and were assigned to one of the five visible minority groups. Overall, Afro-Canadian (Black) subjects were the youngest (mean age was 35.05+/− 10.59 years), often were referred to the CCS with a diagnosis of psychosis, and most often reported a legal history. South Asian and East or Southeast Asians were most likely to be married, while the latter group also was likely to be referred to the CCS with a diagnosis of psychosis. Latin Americans were the most likely to be refugee claimants and the least likely to speak English or French, possibly due to relatively short length of stay in Canada. Approximately 50% of all patients were referred to the CCS by their family doctor or other medical practitioner.

Table 2.

Patient characteristics (N = 401).

Variable	Afro-Canadian (n = 105)		Latin American (n = 40)		Arab or West Asian (n = 73)		South Asian (n = 149)		East or Southeast Asian (n = 34)
	n	%	n	%	n	%	n	%	n	%
Age (mean + /− SD years)	35.05 (10.59)		38.08 (10.80)		40.23 (13.37)		37.70 (11.72)		41.35 (9.45)
Male	56	53.3	22	55.0	39	53.4	60	40.3	12	35.3
Married	25	23.8	15	37.5	28	38.4	86	57.7	17	50.0
Employed	20	19.0	11	27.5	12	16.4	34	22.8	11	32.4
Language Barrier Noted	17	16.2	35	87.5	42	57.5	96	64.4	22	64.7
Length of Stay in Canada (mean + /- SD)	6.11 (7.14)		4.48 (5.75)		7.82 (7.89)		6.71 (7.28)		12.47 (9.73)
Refugee Claimant	56	53.3	28	70.0	17	23.3	60	40.3	3	8.8
Referred by MD	52	49.5	19	47.5	28	38.4	94	63.1	18	52.9
Presence of Psychosis in the Main Final Diagnosis	33	31.4	5	12.5	11	15.1	26	17.4	12	35.3
Legal History	19	18.1	5	12.5	10	13.7	11	7.4	3	8.8
Any Reported Immigration Coercion	43	41.0	18	45.0	16	21.9	30	20.1	3	8.8
Any Reported Medical Coercion	24	22.9	3	8.0	4	5.5	15	10.1	8	24.0

Tables 3–4 display predictors of reported medical coercion (Table 3) and reported immigration coercion (Table 4). These two coercion variables constitute the dependent variables of the study. Independent or control variables include age, gender, marital status, employment status, language barrier, length of stay in Canada, refugee claimant status, referral source, presence of psychosis in the referral diagnosis, legal history, and each of the five visible minority communities. Given the forward stepwise method used to compute the logistic regression models, only statistically significant control variables were included in the tables in addition to the visible minority variables themselves, since these are of principal interest to this study. (More details about these analyses are available upon request.) Any medical coercion (Table 3) was more often reported in Afro-Canadian (Black) patients than in the other visible minority groups (p = .02), although specific measures were not significant on their own, possibly due to low numbers of subjects in the more specific analyses. For medical coercion, youth and the presence of a psychosis diagnosis were predictive in all visible minority groups. For reported immigration coercion (Table 4), being South Asian was predictive of less coercion (p = .03); employment, refugee claimant status, and the presence of a legal history were predictive of more immigration coercion in all groups.

Table 3.

Predictors of reported medical coercion.^a

	B	S.E.	p	Exp (B)	95% CI
Age	−.05	.02	.00	.95	.92–.98
Presence of Psychosis	1.80	.35	.00	6.04	3.02–12.10
Being Afro-Canadian	.83	.35	.02	2.29	1.15–4.57
Constant	−1.00	.64	.11	.37	−
Being Arab or West Asian*	−1.22	.64	.06	.30	.09–1.03
Being East or Southeast Asian*	.62	.67	.35	1.87	.50–6.95
Being South Asian*	−.36	.38	.34	.70	.34–1.46
Being Latin American*	−.26	.66	.69	.77	.21–2.81

^aOmnibus test of model coefficients for Being Afro-Canadian model: χ² = 45.2, df = 3, p < .001.

*These results were calculated separately using the same procedure as Being Afro-Caribbean. For the sake of simplicity, only the ethnic results are included here. Detailed analyses are available on request.

Table 4.

Predictors of reported immigration coercion.^a

	B	S.E.	p	Exp (B)	95% CI
Employment Status	.99	.34	.00	2.70	1.37–5.30
Refugee Claimant	2.52	.31	.00	12.46	6.83–22.73
Legal History	1.11	.43	.01	3.04	1.32–6.99
Being South Asian*	−.66	.30	.03	.52	.29–.93
Constant	−2.39	.30	.00	.09	−
Being Arab or West Asian*	.04	.39	.91	1.05	.49–2.25
Being East or Southeast Asian*	−.24	.86	.78	.79	.15–4.24
Being Afro-Canadian*	.53	.30	.08	1.70	.94–3.05
Being Latin American*	−.31	.41	.44	1.37	.62–3.04

^aOmnibus test of model coefficients for Being South Asian model: χ² = 103.3, df = 4, p < .001.

Discussion

In support of the study hypothesis, we found that Afro-Canadians (Blacks) referred to the CCS reported more medical coercion than their counterparts from other immigrant visible minority groups. Furthermore, analyses of the other minority groups using the same procedures found that South Asians (e.g., patients from Pakistan, India, Sri Lanka, and Bangladesh) reported significantly less immigration coercion. It is important to remember that the CCS represents a “convenience sample” and that the findings are exploratory, and thus, as previously mentioned, should not be generalised to other population samples. This might explain why the CCS database is replete with details on immigration and medical coercion, two phenomena that commonly intersect on the spectrum of immigrant visible minority narratives as they adapt to the host country and the coercive experiences that they experience from immigration and healthcare services.

The absolute number of referrals to the CCS of patients from the various immigrant visible minority categories was the result of factors unexamined by this study. Hence, the reasons for the higher number of Afro-Canadian and South Asian referrals remained unknown. The purpose of this paper, however, was not to elucidate reasons for the differential rates of referral of minority groups to the CCS, but rather to compare rates of reported coercion by members of these groups as recorded by CCS evaluators over a 15 year period.

Afro-Canadians

A considerable literature documents high rates of medical coercion in patients of African (Black) origin (Morgan, 2005; Wolff, 2007; Bhui, 2011; Lawson, 2015), implying that members of this visible minority may be especially at risk of coercive treatment in general, and by psychiatry more specifically; the available literature on immigration coercion is more sparse, but what exists also reports Blacks as particularly at risk (Castille, 2011; Busch & Shore, 2000; Rosen & DiGiacomo, 1978; Brown & Tooke, 1992). Given that Afro-Canadian (Black) patients were not compared to White patients in this study, but to groups who also routinely experience discrimination, the results may suggest a hierarchy of disadvantage in Canadian society, with Afro-Canadians (Blacks) being at greater risk of medical coercion than patients from other immigrant visible minority origins. Clinicians may be more likely to notice and document medical coercion in their Afro-Canadian (Black) patients due to stereotypes that portray Afro-Canadians (Blacks) as more aggressive or less adherent to treatment than other patients (Valenstein, 2001). For the same reason, Afro-Canadians (Blacks) may be primed to report coercion more than members of other groups. On the other hand, the rates of reported coercion in this study may be lower than what takes place in reality due to the vagaries of chart data, which may not always be complete, and the fact that some health professionals may not systematically document coercive measures. Future prospective studies will need to clarify these issues.

The fact that the Afro-Canadian (Black) patients in this study are not associated with significantly elevated levels of reported immigration coercion compared to other immigrant visible minority patients does not imply that problems do not exist, but rather may reflect a relatively high level of baseline coercion in all immigrant visible minority communities. Unfortunately, without social coercion data in the native-born Euro-Canadian population, such comparisons are not possible at this time.

South Asian Canadians

An unexpected finding was that South Asian immigrants and refugees reported less immigration coercion than other groups. There has certainly been a long history of discrimination towards persons of South Asian origin in Canada, with the notorious Komagata Maru incident in 1914, a ban on South Asian immigrants to Canada becoming citizens that was in effect until 1947, and negative stereotypes that have persisted throughout the 20^th Century (Indra, 1979; “Kogamata Maru,” 2011). However, a softening of attitudes by Canadian society toward South Asian immigrants seems to have taken place by the turn of the 21^st Century. In 2001, Coward and Botting suggested that members of the Hindu diaspora in Canada are well established and flourishing and have begun to exert a wide influence on the larger Canadian society (Coward & Botting, 2001). The Canadian government eventually offered an official apology for the Komagata Maru incident (“Justin Trudeau Apologises,” 2016), indicating perhaps a more generalised change of heart toward South Asian communities, with a beneficial effect on how immigration services are implemented and delivered. Politically, Sikh Canadians are in the government as high-level politicians; more than 12% of the current federal Liberal cabinet are Sikhs (Todd, 2018), as is also the present leader of the federal New Democratic Party, Jagmeet Singh.

Another possibility may have to do, once again, with reporting bias, wherein members of South Asian communities are reluctant to complain about problems of the host society, or perhaps have low expectations or lack understanding about their rights to impartial treatment from Immigration Canada and other public services. Evidence from the UK suggests that some South Asian immigrants to that country expect life to be difficult, do not expect anyone to lift them out of difficulty, and are conditioned to put up with adversity (Burr, 2002). These factors may also have a part to play in explaining the study findings.

Limitations

This study has several limitations. First, as previously mentioned, the unique nature of the CCS data limits generalizability of the study findings. The study was not epidemiological by design, so the number of subjects in this study did not reflect the overall immigrant population in Montreal or elsewhere. Our goal was not to make intergroup comparisons generalizable to Montreal, Quebec, or Canada; but rather to examine if particular immigrant visible minority groups referred to a specialised service reported more or fewer coercive measures. Second, another concern has to do with the classification of immigrant visible minority groups, which although based on official Statistics Canada standards, simplified patients' ethnocultural backgrounds. This procedure was necessary to permit large enough numbers in each group to perform statistical analyses; the absolute number of problematic ethnicity assignments was small. For example, we found no significant finding of any reported coercion in the East and Southeast Asian sample, but low numbers made it difficult to draw a firm conclusion. Third, although our results indicated that Afro-Canadian patients reported more coercion than other patients, this does not rule out underreporting by members of other ethnic minorities. Fourth, Europeans are not considered “visible minorities” by the Canadian definition, which would be important in cases where Canadian clinicians themselves belong to a minority status and are operating in cross-cultural fashion. Fifth, the relationship between medical coercion and patient visible minority status might be predicted on the assumption that clinicians are predominantly of Euro-Canadian descent; however, many physicians in Canada are members of visible minorities, so it could be argued that patients consulting these clinicians might receive care more attuned to issues of social adversity due to ethnocultural background. Finally, we caution that negative findings in some groups may obscure the reality that immigration and medical coercion exists for some individuals from all visible minority communities. CCS work with immigrants and refugees since 1999 suggests that a few individuals from all backgrounds start off poorly in Canada, perhaps being put into detention on arrival, followed by a series of coercive experiences: refused refugee claim, threatened deportation, desperate measures resulting in criminal charges, and escalating distress with possible coercive medical treatment. The qualitative experiences of these immigrants and refugees will be the subject of future work.

Conclusion

This study highlights a possible trend in Canadian psychiatry that has already been documented in the UK and the USA: some immigrant visible minorities may be at greater risk of coercive measures, in this case refugees and first-generation immigrants of African descent – not just compared to White native-born patients (as in most previous studies) but also when compared to immigrants from other visible minority communities. This observation is especially important in clinical practice since members of some immigrant visible minorities may attribute adverse life events (including coercive medical care) to discrimination and therefore may be reluctant to use health services due to mistrust and perceived prejudice (Gilvarry, 1999). This reluctance and mistrust would be even more problematic if there had been previous experiences of immigration coercion, which are independently associated with high rates of psychiatric comorbidity (Thompson, 1998; Sultan & Sullivan, 2001; Steel & Silove, 2001). As already mentioned, the use of medical coercive measures may indeed be clinically appropriate in many instances; however, it is of especial importance not to downplay the potential pattern of increased use of coercive measures in specific minority groups (Afro-Canadians or Blacks, in this case). Clinicians need to be watchful of vulnerable groups in their practice and carefully monitor the use of coercion in the routine implementation of care by the teams they lead. Clinically speaking, past and current experiences of immigration and medical coercion are also important topics to explore with patients from visible minorities, given not only the psychiatric comorbidity, but also the impact of the therapeutic alliance with the health system in a foreign country. Furthermore, this study alerts clinicians to the special problems of refugees and the intersectional difficulties they face when they arrive in Canada (immigration and visible minority status), and warns of potentially negative perceptions that coercive interventions may create in these relatively powerless members of Canadian society. Physician advocacy for the patient's rights when faced with immigration coercion (e.g., a patient who suffers from an acutely life-threatening medical condition and is also facing imminent deportation to a war-torn country) is also warranted and clinically indicated; this is an interesting point of discussion for future studies.

Future comparative research of this kind will benefit from studies conducted in emergency and inpatient services (where medical coercion may be most likely to occur), clinics for patients with severe psychiatric disorders, and detention centers for refugees. Comparing rates of reported and documented immigration and medical coercion between immigrants and the native-born in the Canadian context would be a logical next step in this line of inquiry, using epidemiologic methods to provide prospective, generalizable clarification of these issues. Determining which medically coercive acts tend to take place more often in visible minorities, and under what circumstances, would be of critical interest to psychiatrists. Attention to the lived experience of visible minority patients, especially their expectations and understanding of mental health care and the interventions they receive, would also be important in order to shed light on problems when they do occur. Follow up research on this topic will review the lived experience of patients and their families, report in their words the coercion they have encountered, and make recommendations for fostering resilience in members of immigrant visible minority communities.

In summary, the results of this study suggest that, when compared to other minority patients referred to a Cultural Consultation Service in Montreal, Afro-Canadian (Black) first-generation immigrants and refugees were more likely to report medical coercion than members of other foreign-born visible minorities. This finding cannot be explained by language barrier, length of stay in Canada since immigration, refugee claimant status, or legal history. In addition, and controlling for identical variables, first-generation South Asians reported fewer immigration coercive measures when compared to all other foreign-born minority patients. These findings are not the result of comparisons with White patients, as has been the case in most studies to date; but rather comparisons with members of other immigrant visible minority communities in Montreal that are subject to discrimination and prejudice. In light of these findings, there is an urgent need to sensitise clinicians to the difficulties endured by immigrant visible minority populations, so they can provide appropriate advocacy and clinical care.

Supplemental Material

Supplemental material for Reported immigration and medical coercion among immigrants referred to a cultural consultation service

Supplemental Material for Reported immigration and medical coercion among immigrants referred to a cultural consultation service by Don Quang Tran McGill University Andrew G. Ryder Concordia University G. Eric Jarvis in Transcultural Psychiatry

Footnotes

Declaration of Conflicting Interests

The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: No funding was received for this project. The first author (DQT) received a grant from the government of Quebec for his fellowship in Transcultural Psychiatry at the Jewish General Hospital. The authors have no conflicting interests to disclose.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Don Quang Tran, MD, is a Clinical Professor of Psychiatry at Charles-LeMoyne Hospital, affiliated with the Université de Sherbrooke, and founder of the Cultural Consultation Service – South Shore, a direct affiliate of the Cultural Consultation Service at the Jewish General Hospital in Montreal. He completed a fellowship in Transcultural Psychiatry at the Jewish General Hospital (McGill University). His academic and research interests include the process of cultural consultation, the use of coercion in medical and immigration settings, and the acculturation process with its impact on migrants and psychopathology.

Andrew G. Ryder, PhD, is an Associate Professor and Director of Clinical Training in the Department of Psychology at Concordia University. His academic and research interests include cultural psychology and transcultural psychiatry, particularly the cultural shaping of emotions and emotional disorders (with an emphasis on East Asian societies), the acculturation process and its implications for mental health in migrants to Montreal, and the development of better assessment tools to measure key aspects of acculturation.

G. Eric Jarvis, MD, MSc, is an Assistant Professor of Psychiatry at McGill University and Director of the Cultural Consultation Service at the Jewish General Hospital in Montreal. His clinical work involves the psychiatric evaluation and treatment of immigrants and refugees. His current research interests include the relation between psychosis and culture and the process of cultural consultation. Dr Jarvis also writes about the history of psychiatry.

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