POSITION PAPER
A position paper developed by the Canadian Psychiatric Association’s (CPA) Transcultural Psychiatry Section and the Education Committee and approved by the CPA Board of Directors on May 19, 2022.
Columbia University, New York, NY, USA; New York State Center of Excellence for Cultural Competence and Research Area Leader, Anxiety, Mood, Eating and Related Disorders, New York State Psychiatric Institute, New York, NY, USA
Médecins sans frontières, Toronto, ON, Canada.
Department of Psychiatry, McGill University, Montréal, QC, Canada; Divisions of Child Psychiatry and Social and Transcultural Psychiatry, McGill University, Montréal, QC, Canada
Department of Psychiatry, McGill University, Montréal, QC, Canada; Montréal University Health Centre, Montréal, QC, Canada; Inuulitsivik Health Centre, Puvirnituq, QC, Canada
Division of Social and Cultural Psychiatry, McGill University, Montréal, QC, Canada
Department of Psychiatry, Dalhousie University, Halifax, NS, Canada
Social Psychiatry, Charité – Universitätsmedizin, Berlin, Germany; Psychiatric University Clinic of Charité at St. Hedwig Hospital, Berlin, Germany
Indigenous Physicians Association of Canada (IPAC), Vancouver, BC, Canada; First Nations Health Authority (FNHA), Vancouver, BC, Canada
Division of Social and Transcultural Psychiatry, McGill University, Montréal, QC, Canada; Culture and Mental Health Research Unit, Lady Davis Institute, Jewish General Hospital, Montréal, QC, Canada
Recent events in Canada, such as the discovery of graves of Indigenous children at former residential schools and the emergence of Black Lives Matter, have highlighted inequities long endured by Black, Indigenous, Asian and other racialized minorities, and mobilized efforts to address the effects of racism on health, mental health and well-being.1–8 The Canadian Psychiatric Association published a position statement, A Call to Action on Racism and Social Justice in Mental Health, which was prepared by the Transcultural Psychiatry Section, to advocate for diversification of the mental health workforce, cultural and structural safety in educational and clinical environments, dismantling of racist mental health theory and practice, and transformation of institutional structures to make them more equitable and responsive.9 This paper advances that call by taking the position that Canadian psychiatry must act now to redress the ongoing problem of systemic racism through concerted changes in training and mental health services as outlined in this paper. The objectives of this position paper are to:
Race is a culturally constructed identity that divides humanity into groups based on notions of shared ancestry and physical traits presumed to indicate biological attributes.10–13 Racial constructs have varied widely throughout history in response to political and economic priorities of dominant social groups, often to legitimize systems of oppression including slavery, colonialism and apartheid.14–16 North American racial constructs and categories can be traced to the post-Enlightenment period of European history,17 and reflect the interests of powerful groups as well as the human propensity to distinguish ingroup and outgroup and to construct essentialized categories.18 Although human populations show substantial genetic variation as they adapt to local culturally constructed environments,19–21 human genetic variation across groups follows a graduated pattern of single-trait gradients, instead of clustering into discrete racial categories.10,22 The global inter-mixing of human populations has not resulted in distinct groups that would justify a categorical construct like race.23 Moreover, research finds much greater genetic variation among individuals from the same group than between individuals from different racialized groups.24,25
Given the lack of biological support for the concept, it is more accurate to replace the term race with racialized to highlight its socio-culturally constructed nature and use,26 and how this process of social construction undergirds patterns of racial discrimination, oppression and social exclusion27,28 that result in marked inequities in mental health.22,29–31 As Ta-Nehisi Coates puts it, “Race is the child of racism, not the father.”32,p.7
Racism exists at the micro, meso and macro social levels of individuals, institutions and societies and is used to justify the inequitable distribution of power and resources to racialized groups.33–37
The micro level of racism involves individual acts of discrimination and interpersonal violence, including everyday microaggressions, which are acts of disrespect, slights, bias, misrecognition and exclusion that may or may not be deliberate.38 Microaggressions include drawing unnecessary attention to a person’s skin colour, hair or clothing or making stereotyped assumptions about their traits and abilities.39,40 Racism may also be internalized by individuals as negative self-images that cause suffering and impair functioning.41,42 A common assumption is that racism only takes the form of malevolent acts by a few “bad” people.43 Most psychiatrists, including those benefiting from White privilege, would not view themselves as racist. However, while overtly racist acts of hateful speech, discriminatory actions and physical violence are not uncommon, interpersonal expressions of racism often take a less explicit form. The general public is socialized to accept and believe racist discourses, including stereotypes, prejudices and implicit biases. Mental health providers are similarly influenced by pervasive systemic racism “that functions independently from the intentions or 43, p. 20 self-images of individual actors.”
Racism also affects who is considered a credible authority and what counts as knowledge or evidence. Epistemic injustice refers to the way the knowledge claims of some individuals or groups are deemed illegitimate (testimonial injustice) and how they are denied the authority to use their own frameworks to interpret the meaning and validity of truth claims (hermeneutic injustice).44 Epistemic injustice has profound implications at the micro-level in psychiatric settings, where the voices of racialized people may be ignored, silenced or marginalized, not only within clinical encounters, but in the production of knowledge through research and its translation into evidence-informed practice.
Overtly positive stereotypes can also have negative psychosocial effects.45,46 The stereotype of the model minority is often used to situate Asian communities in relation to a racist White-Black hierarchy. In addition to its damaging effects on individuals,47 this stereotype downplays the extent of anti-Asian racism, maintains a racist hierarchy, pits marginalized groups against each other and deepens racism against other racialized groups.48 The concept of model minority highlights how diverse communities experience racism in different ways.
The meso level involves discriminatory or exclusionary institutions, laws, policies and practices through which macro forces impact on communities and individuals.29,35 Institutional racism characterizes racist ideologies and practices embedded in institutions such as government, law-enforcement, education and health care,29,49 while institutional injustice refers to how resources are inequitably distributed to racialized minorities.50 These processes are evident in the racial bias of the criminal justice system (such as police violence, high incarceration rates), teaching curricula, academic hiring and promotion, and the under-representation of racialized communities in many professions, including psychiatry.51–53 Institutional racism may also be expressed through preferential treatment of those who have positively valued racialized identities. The concept of “privilege” refers to the unearned social advantage based on racialized identity that some sectors of society take for granted. White privilege specifically refers to the lack of experienced discrimination, and the power, resources and opportunities available to those assigned to the category of “White” based on the colour of their skin.54
At the macro level, racism manifests in structures and systems. Structural racism recognizes that racism cannot be reduced to single institutions or actors but is built into the structure of society in terms of social class and caste, and the organization of space.29 Structural racism results in structural violence, including poverty, educational and health inequities, and lack of recognition or sovereignty.55 Systemic racism points to the ways in which institutions, structures, ideologies and practices work together to make racism part of how the social system functions. Importantly, systemic racism can occur even when individuals who participate in the system are not consciously racist.
Environmental racism is another macrosocial phenomenon that refers to racialized groups being differentially exposed to unhealthy environmental conditions.56–58 This occurs on local and global scales and is especially salient for Indigenous Peoples, many of whom have a close connection to the land, so that environmental depredations represent profound attacks on the person and community.59–62
Racism affects all areas of life.63 Based on 2016 Canadian Census data, racialized populations had a higher unemployment rate than their non-racialized counterparts (9.2 vs. 7.3 per cent) and earned less money (78 cents and 59 cents for racialized men and women respectively per dollar earned by non-racialized men), with disparities among racialized immigrants extending for three generations and beyond.64 Indigenous people face ongoing structural violence, rooted in the legacies of colonization including the residential school system and the Sixties Scoop, that perpetuates limited access to clean food and water, stable housing, education and adequate health funding.65,66
The health disparities experienced by racialized groups include shorter life expectancy and higher rates of obesity, high blood pressure, cardiovascular disease and diabetes.30 The concept of allostatic load,67 which describes physiological alterations due to chronic stress, may account for some of the effects of racism on health conditions.68 The interaction of social adversities and lack of access to health resources also contributes to inequities.69
Microaggressions contribute to an interpersonal burden that has physical, psychological and social consequences.38,70 Microaggressions are ubiquitous, occurring in personal and work relationships as well as public settings.10,15 Coping with microaggressions in these contexts requires specific strategies—all of which demand energy and time.71,72 The cumulative exposure to these discriminatory acts has long-term health effects on people from ethnic minorities.73
Racialized individuals, particularly Black and Indigenous people, have more negative experiences in the education system, including exposure to racial stereotyping and hostility, lack of encouragement to pursue education, lack of role models and impoverished opportunities,74–76 which, along with other inequalities, contribute to lowered expectations, unemployment and the overrepresentation of racialized people in the Canadian criminal justice system.77 In addition, Black and Indigenous children are overrepresented in the Canadian child welfare system, which may be related to implicit biases and the effects of systemic violence and racism.78–80
Historically, Canadian law has colluded with racist agendas to disadvantage communities of colour.81 The Indian Act (1876/1985) considered Indigenous Peoples as wards of the state and instituted oppressive measures.82 Although modified through the years, the Indian Act continues to contribute to structural racism.83 Racialized individuals and communities experience increased police and justice system contact.84–86 One study found that whereas Indigenous people make up only five per cent of the general population, they account for 30 per cent of Canadian federal inmates.87 Black youth in Canada are twice as likely as White youth to be searched by the police, 50 per cent more likely to be detained before trial, have more conditions imposed when given bail, and are incarcerated at four times the rate as Whites.88 Recent studies in Montreal found that Black psychiatric patients were at higher risk of coercive intervention,89 particularly when the courts or police were involved.90
There is a long history of anti-Asian racism from the building of the Canadian Pacific railroad to the Chinese head tax, the Chinese Exclusion Act and the Japanese Canadian Internment in World War II, to recent anti-Asian racism in response to the COVID-19 pandemic. In a 2021 national survey, 50 per cent of Chinese Canadians experienced being insulted because of the pandemic, and 43 per cent were personally threatened or intimidated. In the first year of the pandemic, about 1150 anti-Asian racist attacks were voluntarily reported to websites, including 11 per cent involving physical contact and 10 per cent being coughed or spat on.91
Racialized populations also suffer when discriminated against based on their religion, with intersecting ethnic and race-based prejudice. Many instances of hate crimes that target religious minorities have been documented in Canada.92–95
Racism is deeply embedded in the languages we speak and the structures of our society96,97 and is evident in the institutional practice of psychiatry.98,99 As reflected in the writings of colonial psychiatrists like Antoine Porot and J.C. Carothers,100,101 racism has shaped the institutions of psychiatry within countries and internationally.102 Colonial writers promoted stereotypes of racialized communities that persist in psychiatry to the current day.103 Despite well documented health care disparities for people of colour and immigrants, racism remains a persistent problem in Canadian medicine and psychiatry.104–106 In the Canadian context, racism and discrimination have been under-reported, undetected and unacknowledged even though structural racism affects patients and caregivers at all levels of society.107,108
Racialized immigrants and minorities face systemic and structural difficulties accessing mental health care.109 Some of these difficulties include limited financial resources, a poor understanding of mental health-care systems, lack of services in areas where racialized people live and limited availability of interpreters for newcomers.110 Access to care for racialized minorities born in Canada, in contrast to immigrant racialized minorities, has been little studied, but some national data suggest a link between discrimination and poor access to services, with worse mental health outcomes, for example, in perinatal conditions like post-partum depression.111,112
Despite well-documented employment inequities in Canadian higher education,113 discriminatory practices in academia that exclude people of colour are often overlooked.114 In general, data on the ethnicity of Canadian physicians is difficult to obtain, but available information shows a lack of diversity at all levels from health ministers to medical school faculty.115 The 2016 Canadian Census found that although Indigenous peoples represented four per cent of the population fewer than one per cent of medical specialists and general practitioners identified as Indigenous.116
According to the Black Canadian National Survey Interim Report,117 49 per cent of Indigenous and 70 per cent of Black Canadians experience racism and most report that racism is a problem in health care. In a systematic review and meta-analysis, Paradies et al.118 found that while racism is significantly correlated with poor health status, the association between racism and poor mental health, especially post-traumatic stress disorder (PTSD), was twice as large as that for poor physical health. Experiences of racism carry serious short- and long-term consequences for racialized people, including impaired life satisfaction and self-esteem119 and more helplessness and suicide behaviour.120 Systemic racism also contributes to poor quality of health care for Indigenous people121,122 and avoidance of mental health services by Chinese, other Asian, and Black Canadians.123
Additional problems that racialized patients may face due to racism include disparities in diagnosis and course of illness, such as: being diagnosed with more psychiatric disorders overall,124–129 being misdiagnosed with psychotic disorders instead of depression and PTSD,130,131 developing more delusional ideation or other psychotic symptoms,132,133 having a relatively more severe course of illness134,135 as reflected in an excess of police and ambulance contact prior to emergency psychiatry evaluation,136 and being more likely than non-racialized patients to be involuntarily admitted to the hospital.137 A meta-analysis found anti-Asian racial discrimination to be associated with mental distress, with Chinese and South Asian ethnicities being independent predictors of illness severity, presence of psychotic symptoms and involuntary hospital admission.138 Among various ethno-racial groups studied, Chinese Canadians reported the weakest sense of belonging to local communities and the poorest self-rated mental health.123
Despite growing recognition of the need for anti-racist practices, few training programs for mental health professionals address issues of racialized identity and racism.78,139–141 There is a crucial need to educate professionals in ways to identify and address the effects of racism on their patients and themselves, as well as on the health-care institutions and systems in which they work. Professionals also need to understand how the colonial past and present, as well as histories of racism and exclusion, affect current practices. The unexamined racism in the profession risks making psychiatry an unattractive career choice for potential trainees of colour.
Curriculum development can begin by outlining key learning objectives in terms of attitudes, skills and knowledge, using the CanMEDS Framework, and describing competencies that can be evaluated with Entrustable Professional Activities (EPAs).142 These in turn must be integrated with In-Training Evaluation Reports (ITERs) and Royal College examination content whenever possible because evaluation drives learning and signals institutional commitment.143
Residency curricula need to ensure that trainees deepen their understanding of the intersectional nature of racialized identity, racism, power, privilege and oppression,144 while being grounded in the social and historical contexts of diverse marginalized and oppressed groups.145 Racism needs to be understood on personal, relational and eco-social levels,9,49,146 and across its various forms and contexts, including internalized racism, micro-aggression, interpersonal racism, institutional racism, structural/systemic racism, colonial histories of racism, and ultimately, how these issues interweave to produce disparities in mental health.147 Training programs need to provide safe spaces and role models to enable faculty and trainees to reflect on their own biases106,148–150 and focus on developing the necessary knowledge, skills and attitudes to deliver culturally safe care.149,151–153 Being aware of racism is not enough: trainees and psychiatrists alike must be actively opposed to racism and have the tools to address biases and discriminatory practices.
To recognize and address systemic racism, training needs to emphasize a more systemic approach, including skills in assessing family, socio-cultural factors and structural inequalities,154 promoting inclusivity of spiritual, cultural, systemic and environmental dimensions and the perspectives of diverse clients.155 A systemic view can better equip clinicians to create safety in the micro-dynamics of the clinical encounter and appraise the social dimensions of suffering.156
Reflection on the history of structural and systemic racism should be linked to actions that can transform the health-care system.157,158 Making links from theory to clinical practice and to systemic advocacy is critical to creating meaningful change at all levels.159,160 This requires training to address racism at micro, meso and macro levels to facilitate working with racialized individuals, families and communities through collaboration and collective empowerment.8,161
Undergraduate and postgraduate medical education need to have an integrated developmental approach to addressing racism through providing knowledge and conceptual frameworks in didactic presentations, cultivating attitudinal change through experiential and reflective learning, and building clinical and advocacy skills through supervision and modelling.9, 162,165 Learner-led discussion groups can provide additional spaces for dialogue complementary to the formal curriculum.166,167 Above all, racialized trainees need a safe space to learn, with mentors and supervisors who recognize and address the racism that they encounter in patient interactions, as well as with colleagues, institutions and the wider society. Some trainees and faculty may require specific mentorship from supervisors with lived experience of racism.
Faculty need to prioritize anti-racism initiatives to establish trust and ensure sustainability, and they must be trained in anti-racist pedagogy, cultural safety, cultural humility, and cultural and structural competence to address issues of racism that appear in clinical supervision.163,168–172 Engaging community members and service users in training is key to unmasking the lived reality of racism and confronting biases and stereotypes. Facilitating long-term interdisciplinary and community collaborations can foster self-transformation and collective action.
Facing the complexity of historical and ongoing racism, many clinicians and members of racialized communities may have doubts about whether mental health-care systems can ever provide equitable care. Rather than retreating from their responsibility, all clinicians and institutions must critically examine the biases embedded in practices and policies to avoid perpetuating racism and discrimination.173 Ensuring diversity in the health-care workforce and conveying a willingness to acknowledge and discuss issues of racism can contribute to more equitable access to care.174 Explicit anti-racist actions are needed at the micro, meso and macro levels (Table 1).
Consistent with the previous training recommendations, Cénat147 outlines core approaches to anti-racist practice for health-care practitioners at the micro level, emphasizing self-awareness, recognition of diversity within and among groups, knowledge of the impacts of racism and discrimination on mental health and clinical services, and specific skills in interviewing, assessment and treatment. Antiracist policies and laws against discrimination should be applied to health-care settings, as reflected in documents like Jordan’s Principle175 and Joyce’s Principle,176 which assert Indigenous rights to equitable services. Anti-racist practices in clinical work begin with self-awareness, openness and the willingness to explore issues with colleagues and patients.
Unfortunately, many clinicians either avoid addressing racism altogether or do not distinguish non-racist from anti-racist attitudes.74,75,177 A non-racist attitude refers to passive rejection, even denial, of racism, while an anti-racist attitude implies active efforts to acknowledge systemic racism and remove its effects from the structures of society.178 When patients or colleagues raise issues related to racism, their experience may be minimized, discounted or ignored by those who adopt a ‘non-racist’ attitude. Clinicians may become defensive, deflecting, denying or even blaming discriminatory experiences on victims’ perceptions, attitudes and actions or viewing patients’ legitimate mistrust as an expression of suspicious or paranoid thinking.173 These responses have been reported by patients from racialized communities who may then disengage, or remain untrusting and unwilling to speak openly about their experiences of racism.153,179 Similarly, racialized psychiatrists may experience micro-aggressions on an almost-daily basis from their patients or colleagues. These experiences often go unseen so may be unnoticed by peers and health administrators. Acceptance of the reality of systemic racism is a necessary first step towards change that will support anti-racism advocacy, allyship and equity efforts.
Countering racism at a meso level requires attention to institutional structures and routines, such as providing access to linguistic interpreters and culture brokers. For psychiatry, this may include modifying the multidisciplinary clinical team, ward, department, faculty, hospital and other practice settings180 to reduce access barriers and improve the quality of services. Countering racism at a macro level requires acting at a societal, policy and broader structural level through program development, advocacy and research that calls for change in the structures and practices that perpetuate racism in different sectors and institutions (e.g., police, immigration, education, employment, health care). Ensuring diversity within the profession is an important step toward equity and institutional change. In Canada, where Indigenous Peoples116 and many other groups are under-represented in the health professions, funding and hiring strategies that lead to recruitment of minority medical students and residents can contribute to a long range shift within psychiatry toward greater diversity and inclusiveness in the mental health workforce and equitable representation of racialized groups.181,182 More than mere numerical representation, racialized psychiatrists and trainees need the mental health system to change to become actively anti-racist and welcoming of diversity.
One way to increase diversity in the profession over the long term would be for organizations like the CPA to partner with other professional medical organizations, like the Canadian Medical Association and Canadian medical schools, to develop community partnerships with under-represented groups to increase the number of competitive medical school applicants. Reserving training spots, providing scholarships or financial support, and increasing international medical graduate integration have been successful strategies to increase equitable representation for Black, Indigenous and other underrepresented racialized groups. Educators can work with Black medical student and physician organizations and Indigenous physician organizations to develop other strategies for equity and inclusion. In addition, addressing racism and inequities embedded in career advancements, academic promotions, and leadership and power opportunities, as well as support for racialized professionals to prevent burnout, are urgently needed. Given the limited number of racialized professionals in psychiatry, they tend to become overburdened and need resources to function effectively. Organizations need to be sensitive to the time, emotional toll and distraction associated with these tasks and give appropriate recognition for these roles.
The knowledge and experience of diverse psychiatrists is crucial to improving care for racialized patients and working toward broader change in health-care institutions and systems.106,163,183 In the meantime, health-care institutions and professional organizations must stop current “colourblind” approaches that are common and continue to perpetuate discrimination against people of colour.184 One important step would be for each academic department of psychiatry in Canada to identify an equity, diversity and inclusion (EDI) leader. This new position would be given significant status, responsibilities, resources and decision-making power to encourage and support clear anti-racist policies that could be implemented at the meso and macro level (see Table 1). This should however be considered a starting point and not a sign that racism has been dealt with adequately at the institutional level.
The structural inequities of Canadian society disproportionately affect racialized peoples. Redressing these inequities requires structural interventions including advocacy, public health interventions and policy change. Psychiatrists can engage on these issues at multiple levels: at the micro level by modifying clinical care and taking personal responsibility for developing knowledge and skills in anti-racism, at the meso level by adapting programs, and at the macro level through systemic advocacy, that is, working to modify policies or procedures that broadly impact vulnerable groups or communities.185 Although not all clinicians will address each of these levels, it is important to understand how they are interrelated. Offering clinical care to racialized populations, without attending to higher-level structural issues, may unintentionally treat mental health difficulties as problems arising from the individual rather than due to systemic racism. Specialized programs, which include anti-oppressive and anti-racist principles, offer meso-level interventions. Examples of such programs are SAPACCY, a program specifically created for African Canadian and Caribbean Youth,174 ethno-specific services developed in partnership with communities such as Hong Fook, Across Boundaries and the Asian Initiative in Mental Health in Toronto,186 and the Cultural Consultation Service in Montreal.155 In addition, there are programs that work collaboratively and respectfully with Indigenous mental health services by forging partnerships with rural, remote and isolated Indigenous communities to solve locally identified mental health challenges.187
Engaging in structural advocacy is less familiar to many psychiatrists.160 This form of advocacy targets root causes of inequity which impact health such as detention of migrants, family separation, precarious employment, culturally unsafe social institutions, racist media representation, poverty and homelessness.188 To engage at the structural level, psychiatrists may join or initiate advocacy coalitions that work with affected communities and employ a diversity of tactics, such as organizing open letters and opinion pieces,189 to address policy, judicial, legal or political engagements. Advocacy aims not only to correct structural racism but to ensure that marginal voices are heard in the context of human rights and social justice frameworks.190
Preventing racism by changing institutions, attitudes and practices requires ongoing dialogue among stakeholders to clarify competing values, provide a safe space for critical self-reflection, and develop collaborative interventions.191,192 This position paper cannot replace ongoing discussions, seminars and workshops at the local level to determine how to decolonize curricula and prevent racism in policy and clinical practice. Advocacy efforts are not without risks;193 for example, in efforts to rapidly gain consensus, the complexity of issues and the diversity of experience within groups may be oversimplified with the result that racialized communities may be stereotyped as helpless, passive and lacking resilience.192 To avoid these pitfalls, participatory engagement of communities that have largely been excluded from research or planning efforts, will be key to ensuring that the advocacy process is collaborative, co-developed and empowering rather than paternalistic or merely tokenistic.194
Diversity is a great strength of Canadian society. However, racialized and minoritized groups continue to face bias and discrimination in psychiatry. These forms of injustice will not be resolved by simply adopting an attitude of ‘colour-blindness’ that ignores the lived experience and structural embedding of racism. Denial of systemic racism and structural violence operates at all levels of Canadian society.195 This paper takes the position that Canadian psychiatry must act now to redress the ongoing problem of systemic racism through concerted changes in training and mental health services as outlined in this paper. Within the profession, psychiatrists may feel unconcerned or unjustly targeted, insisting that they do not have racist attitudes or beliefs and are not “privileged.” Unfortunately, indifference and defensiveness perpetuate systemic racism. The Turpel-Lafond Report (2020) concluded that racism pervades health-care systems, but specific actions endorsed by policy can affect change.196 Progress comes about when individuals reflect on how their own beliefs and behaviours contribute to racism in Canadian society. Countering racism at a micro level (personal or clinical) starts with self-reflection and psychologically and culturally safe dialogue. This requires acknowledging uncomfortable feelings, recognizing the experiences of others, realigning one’s privileged status and developing equitable relationships, leading to advocacy for systemic change at the meso and macro levels. Professional organizations, like the CPA, must lead in this process. Psychiatry must become a safer professional environment for diverse trainees as well as patients. The essential systemic changes will come about as psychiatrists work in partnership with other professions, government and communities. Institutions that actively counter racism can gradually transform the structures of discrimination that harm our patients, our colleagues and ourselves contributing to a more equitable health-care system and society.
The authors are grateful to the CPA Board, especially to those members who reviewed and gave feedback on this position paper: Dr. Harry Karlinsky, Dr. Vanessa Lantz, Dr. Catherine Hickey, Dr. Leon Tourian, Dr. Michael Mak, and Dr. Michael Mercer.
1 Division of Social and Transcultural Psychiatry, McGill University, Montréal, QC, Canada; Cultural Consultation Service and Culture and Psychosis Working Group, Jewish General Hospital, Montréal, QC, Canada
2 Equity and Inclusion Council; Department of Psychiatry, University of Toronto, Toronto, ON, Canada
3 Department of Psychiatry, Queen’s University, Kingston, ON, Canada; Community Psychiatry, Providence Care, Kingston, ON, Canada
4 Department of Psychiatry, University of Toronto, Toronto, ON, Canada
5 School of Psychology, University of Ottawa, Ottawa, Ontario, Canada; Interdisciplinary Centre for Black Health, University of Ottawa, Ottawa, ON, Canada
6 Department of Psychiatry, University of Sherbrooke, Sherbrooke, QC, Canada
7 Department of Psychiatry, University of Toronto, Toronto, ON, Canada; Asian Initiative in Mental Health, University Health Network, Toronto, ON, Canada; Society for the Study of Psychiatry and Culture, Beverly Hills, CA, USA.
8 Margaret and Wallace McCain Centre for Child, Youth, and Family Mental Health, Centre for Addiction and Mental Health, Toronto, ON, Canada; Department of Psychiatry, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
9 Montréal Children’s Hospital (MCH), McGill University Health Centre (MUHC), Montréal, QC, Canada; Inuulitsivik Health Centre, Puvirnituq, QC, Canada; Ungava Tulattavik Health Centre, Kuujjuaq, QC, Canada
10 McGill University, Montréal, QC, Canada
11 Department of Psychiatry, McGill University, Montréal, QC, Canada
12 Department of Psychiatry, University of Ottawa, Ottawa, ON, Canada; Ottawa Newcomer Health Centre, Ottawa, ON, Canada; Wholistic Health and Wellness, Mohawk Council of Akwesasne, Akwesasne, QC, Canada
13 Division of Social and Transcultural Psychiatry, Department of Psychiatry, McGill University, Montréal, QC, Canada; Lady Davis Institute and Sherpa Research Institute, Montréal, QC, Canada
14 Department of Psychiatry, McGill University, Montréal, QC, Canada; Research Ethics Board, CIUSSS du Centre-Ouest-de-l’île-de-Montréal, Sir B. Mortimer Jewish General Hospital, Montréal, QC, Canada; Lady Davis Institute for Medical Research, Sir B. Mortimer Jewish General Hospital, Montréal, QC, Canada
15 Columbia University, New York, NY, USA; New York State Center of Excellence for Cultural Competence and Research Area Leader, Anxiety, Mood, Eating and Related Disorders, New York State Psychiatric Institute, New York, NY, USA
16 Médecins sans frontières, Toronto, ON, Canada.
17 Department of Psychiatry, McGill University, Montréal, QC, Canada; Divisions of Child Psychiatry and Social and Transcultural Psychiatry, McGill University, Montréal, QC, Canada
18 Department of Psychiatry, McGill University, Montréal, QC, Canada; Montréal University Health Centre, Montréal, QC, Canada; Inuulitsivik Health Centre, Puvirnituq, QC, Canada
19 Division of Social and Cultural Psychiatry, McGill University, Montréal, QC, Canada
20 Department of Psychiatry, Dalhousie University, Halifax, NS, Canada
21 Social Psychiatry, Charité – Universitätsmedizin, Berlin, Germany; Psychiatric University Clinic of Charité at St. Hedwig Hospital, Berlin, Germany
22 Indigenous Physicians Association of Canada (IPAC), Vancouver, BC, Canada; First Nations Health Authority (FNHA), Vancouver, BC, Canada
23 Division of Social and Transcultural Psychiatry, McGill University, Montréal, QC, Canada; Culture and Mental Health Research Unit, Lady Davis Institute, Jewish General Hospital, Montréal, QC, Canada
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