7mar2022 Sturm2017 Article CulturalSensitiveCareProvision

Cult Med Psychiatry (2017) 41:630–655
DOI 10.1007/s11013-017-9538-7
CLINICAL CASE STUDY
Cultural Sensitive Care Provision in a Public Child

and Adolescent Mental Health Centre: A Case Study
from the Toulouse University Hospital Intercultural
Consultation
Gesine Sturm1,2 • Sylvie Bonnet2 •

Yolaine Coussot2 • Katja Journot2 •
Jean-Philippe Raynaud3,4
Published online: 2 May 2017

Springer Science+Business Media New York 2017
Abstract Child and adolescent mental health services in Europe are confronted with
children with increasingly diverse socio-cultural backgrounds. Clinicians encounter
cultural environments of hyperdiversity in terms of languages and countries of origin,
growing diversity within groups, and accelerated change with regards to social and
administrational situations (Hannah, in: DelVecchio Good et al. (eds) Shattering
culture: American medicine responds to cultural diversity, Russel Sage Foundation,
New York, 2011). Children and families who live in these complex constellations
face multiple vulnerabilizing factors related to overlapping or intersecting social
identities (Crenshaw in Univ Chic Leg Forum 140:139–167, 1989). Mobilizing
existing resources in terms of social and family support, and encouraging creative
strategies of interculturation in therapeutic work (Denoux, in: Blomart and Krewer
(eds) Perspectives de l’interculturel, L’Harmattan, Paris, 1994) may be helpful in
order to enhance resilience. Drawing from experiences in the context of French
transcultural and intercultural psychiatry, and inspired by the Mc Gill Cultural
Consultation in Child Psychiatry, we developed an innovative model, the Intercul-
tural Consultation Service (ICS). This consultation proposes short term interventions
to children and families with complex migration experiences. It has been imple-
mented into a local public health care structure in Toulouse, the Medical and
Psychological Centre la Grave. The innovation includes the creation of a specific
& Gesine Sturm

gesine.sturm@gmail.com
1
Laboratoire LCPI (EA4591), Université de Toulouse Jean Jaurès, Toulouse, France
2
CMP, SUPEA (service universitaire de psychiatrie de l’enfant et de l’adolescent), CHU de
Toulouse, Toulouse, France
3
Faculté de médecine de Toulouse, Université Paul Sabatier, Toulouse, France
4
SUPEA (service universitaire de psychiatrie de l’enfant et de l’adolescent), Inserm URM1027,
CHU de Toulouse, Toulouse, France
123
Cult Med Psychiatry (2017) 41:630–655 631
setting for short term therapeutic interventions and team training via shared case
discussions. Our objectives are (a) to improve outcomes of mental health care for the
children through a better understanding of the child’s family context (exploration of
family dynamics and their relatedness to complex migration histories), (b) to enhance
intercultural competencies in professionals via shared case discussions, and, (c) to
improve the therapeutic relationship between children and professionals on the basis
of the work with the family and the dialogue with the team. In our paper, we present
the rationale and functioning of the ICS and illustrate our work with a case study. The
presentation of the case uses the Mc Gill B-version of the Cultural Formulation,
combined with a relational and process oriented reflection on the intercultural
dynamics that unfold during the encounter with a family.
Keywords Culturally sensitive child mental health Hyperdiversity

Intersectionality Interculturation Cultural formulation
Introduction
In the following, we describe and discuss a cultural consultation service which has
been implemented into a public service of mental health care in Toulouse. We will
first describe the challenges in the field of mental health care of children within a
culturally diverse context, and draw a picture of the specific situation in France and
in Toulouse. We then discuss central concepts which we use in order to better
understand the effects of diversity on our clinical work such as the notions of
hyperdiversity (Hannah 2011), intersectionality (Crenshaw 1989) and intercultur-
ation (Denoux 1994). After this, we describe our consultation (the Intercultural
Consultation Service, ICS) while highlighting similarities and differences between
the ICS and other existing cultural consultations in France. Finally, we present and
discuss a case study, using the B-version of Mc Gill Cultural Formulation,
completed by a reflection on intercultural relational dynamics that emerged in this
situation. We conclude with perspectives on the development of our work and the
possibilities to transfer its rationale and functioning to other contexts in the field of
mental health care of children and adolescents.
Intercultural Mental Health Care for Children
During the past decades, the development of accessible and appropriate mental
health care for children and adolescents with a migration background has become an
important concern in Europe. The recent arrival of a significant number of child and
adolescent refugees has further drawn attention to specific vulnerabilities of migrant
children,1 confronting health care institutions with the urgent need to adapt mental
1
Even though experiences of flight and armed conflict have specific consequences on mental health, the
distinction of refugee and migrant youth is not always very clear—children and families who migrate for
economic reasons may be exposed to violence and traumatic experiences before and during the flight, and
some migrants fleeing from conflict decide not to apply for asylum.
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632 Cult Med Psychiatry (2017) 41:630–655
health care services and to promote resilience through appropriate interventions

(Anagnostopoulos et al. 2016; Hebebrand et al. 2016). Depending on pre-migration
and migration experiences, the living conditions in the host country, and the social
situation and legal migration status, some migrant children are extremely
vulnerable. Mental health problems are not always easily detected, especially when
health professionals are not familiar with intercultural situations which confront
them with complex transnational family organizations, problems related to the
adaptation in the host country, and the complexity of identity construction in the
context of multiple cultural affiliations (Guzder 2014; Measham et al. 2014). The
challenge is not only to detect health and developmental problems in order to
prevent difficulties over the long run, but also to recognize existing social and
personal resources in order to enhance resilience. As Derluyn et al. note in an article
on mental health of migrant children in Belgium, ‘‘migration experience cannot be
considered as an isolated factor, but an overall picture of different risk and
protective factors in every child should be taken into account when considering the
child’s emotional well-being’’ (Derluyn, Broekaert, and Schuyten 2008:59). While
research on refugee and migrant children gives evidence on important risks and
vulnerabilities, especially for those who travelled without their parents, research
also indicates important resources that can be mobilized if the conditions are
appropriate, even in the most vulnerable populations (Sleijpen et al. 2015).
Models of Service Provision in Child Mental Health Care for Migrant

Youth
Different models of service provision have been developed to establish equal access
to quality care, prevention, and promotion of resilience for migrant and minority
youth. Measham et al. distinguish three types of adaptations (Measham et al. 2014):
– Ethnic specific or culturally sensitive services for minority groups.
– Culturally responsive services in mainstream institutions.
– Preventive services and mental health care interventions in schools (collaborative
health care model).
The Cultural Consultation of the Mc Gill Transcultural Child Psychiatry team (op
cit.), established a collaborative health care program, with actions within the Montreal
Children’s Hospital (consultations with children and families, staff-supervision and
training and a more general teaching activity in the Multicultural Program), while
other actions took place in local neighborhoods in cooperation with local institutions
and associations. These actions include prevention of mental health problems and
fostering resilience through arts-based interventions in schools, joint consultations
with multiprofessional teams, supervision and teaching (Rousseau et al. 2005).
Recently a cultural consultation service, the Tower Hamlets Cultural Consulta-
tion Service (ToCCS), has been implemented in East London. The ToCCS proposes
multiple levels of service provision and commissioning in order to address structural
and individual determinants of health inequalities. Clinical consultations, workforce
development and organizational consultations are combined in order to improve
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access to quality health care for minorities (Bhui et al. 2015). This system oriented
approach includes organizational and institutional changes in order to understand
and transform professional ‘‘cultures of care’’ (Ascoli et al. 2012). It could be
inspiring for the work in child mental health care as inter-institutional cooperation
with different actors referring to different cultures of care (and education) play an
important role in this field.
In France, (inter- or trans-)2 cultural consultations in child mental health care
exist in several places, most of them being integrated into the public health care
system. The transcultural consultation of Moro and her team at the Avicenne
hospital in Paris is the most established example (Moro 1994, 2014; Sturm, Nadig,
and Moro 2011; Measham et al., 2014). It has been developed in the context of the
French ethnopsychanalytic tradition which underlines the importance of culturally
informed narratives about a child’s problems. While some authors in this tradition
(such as Tobie Nathan) have insisted on the importance of ‘‘traditional’’ cultural
representations (Nathan 1993), Moro’s approach introduces a dynamic conception
of culture and conceives of the dialogue between therapists, cultural mediators and
families as a process of co-construction of meanings (Moro 2011). Other
consultations working with similar references exist in Paris, Bordeaux and Dole.
The Intercultural Consultation in Toulouse combines elements from the French
ethnopsychoanalytic tradition (the co-construction of narratives on the child’s
problem with the help of the interpreter) with an intercultural perspective, where the
exploration of conflicts and difficulties resulting from diverging cultural, social and
gendered perspectives within the family, but also in the dialogue between families
and professionals play a central role.
The above mentioned consultations in France are part of mainstream institutions
and integrated into the sectored mental health care system. They propose specialized
culture-sensitive interventions as a supplement to existing health, educational and
social care interventions. Cooperation with and training of mental health care
professionals is proposed in joint consultations, supervisions and case analysis.
Culture and Ethnicity in Intercultural Child Mental Health Care:

Traditions and Conceptualizations
On a conceptual level, growing diversity, increasingly complex migration patterns

and accelerated cultural change demand a critical reflection about the concepts of
culture and ethnicity in the context of mental health care. The colonial heritage of
the notions of ethnicity and culture and the risk of stigmatizing, exotizing and
essentializing constructions of the ‘‘cultural other’’ have been highlighted in cultural
2
The terminology in France is variable. While the term ‘‘transcultural’’ is mostly used with reference to
Georges Devereux in order to stress the possibility to overcome cultural difference and to refer to
universal psychic processes, the term ‘‘intercultural’’ is mostly used with reference to the French
intercultural psychology with a specific concern for the impact of real, imagined and attributed difference
and its transformation in cultural contacts (Cohen-Emerique 2011; Guerraoui and Pirlot 2011).
123
anthropology (Clifford and Marcus 1986). Reified perceptions of the cultural other
tend to mask not only common humanity but also the impact of social positions,
gender dynamics and inequalities (Abu-Lughod 1991). Processes of cultural change
and métissage have often been underestimated, and the idea of clearly delimited
homogenous cultures or communities appears to be an artefact which does not
reflect reality (Amselle 1990; Baumann 1996, 1999). Recent discussions in the field
of mental health care for migrants and minorities in the US and in Europe respond to
the challenges of these critiques while developing a specific interest in growing
diversity and cultural complexity (DelVecchio Good et al. 2011; Cattacin and
Domenig 2015).
Different levels of diversity such as cultural affiliations, religion, gender, age, and
social, economic and administrational situations coexist and interact, creating
different constellations of social and personal resources, needs, and structural
vulnerabilities within cultural minorities (Bourgois et al. 2016). While describing
this kind of complexification, Hannah proposes the concept of hyperdiversity.
Cultural environments of hyperdiversity are ‘‘highly diverse (in terms of race and
ethnicity as well as social class, immigration status and religion), dynamic
(unstable or undergoing change), and multidimensional (individuals may choose to
identify with broad racial and ethnic categories or narrower categories such as
country of origin, neighbourhood, or sexual orientation)’’. (Hannah 2011:41). These
complexities have a direct impact on health care provision, as they create specific
needs which can only be perceived and addressed if different forms of diversity, and
inequity and their interaction are considered. Some people may become extremely
vulnerable because their ‘‘profile’’ exposes them to different types of discrimination
while their access to social or other resources is limited by other dimensions of that
same profile. In Black Feminist theory, Crenshaw introduced the notion of
intersectionality in order to describe how the interaction between different factors of
discrimination can lead to specific vulnerabilities. She describes how Black women
are discriminated both as women and as Blacks, and deprived of protective
resources specific to one identity because of discrimination related to them being
part of the other minority (Cho, Crenshaw, and McCall 2013; Crenshaw 1989). The
notion of intersectionality may also be useful for tackling the impact of racism and
discrimination on mental health while considering the interaction with other factors
linked to diversity and inequality.
Considering Culture in French Mental Health Care
In France, the discussions about the concepts of culture and ethnicity are strongly
influenced by the Universalist tradition of the French Republic (Fassin and
Rechtman 2005). Cultural or ethnic attributes are not to be used in order to define
specific needs or rights for any part of the population, and the use of ‘‘ethnic
statistics’’ including information about the ethnic background of a person is
prohibited. Evidently this has a strong impact on research on inequalities concerning
cultural or ethnic minorities in the field of health care which is almost inexistent in
123
France.3 The term ethnicity is barely used and is easily associated with colonial
heritages (Mouchenik 2006).
In the field of social interventions and mental health care, ethnopsychiatric
approaches have introduced the idea of specific needs of specific cultural groups and
underlined the necessity to adapt mental health care to these needs. Tobie Nathan
(1986) became a prominent, but also much debated figure in this context. He
proposed to work in tight cooperation with cultural brokers in order to reconstruct
the patient’s ‘‘cultural frame’’ and created specific settings for the therapy of
migrants, as a ‘‘multicultural group therapy’’ where therapists from different cultural
origins work together with one patient or family in order to facilitate the
construction of narratives that are organized by cultural representations from the
patient’s cultural background. Nathan underlined the importance of ‘‘traditional’’
cultural representations and healing techniques for the immigrant patients he treated
in therapy. Nathan’s approach provoked a passionate debate about the possibilities
and pitfalls related to the use of ‘‘culture’’ in therapy. Authors such as Fassin (2000)
highlighted the dangers of stigmatizing via the essencialization of cultural
difference, the need to reflect on colonial history, and the risks related to the use
of an exotizing representation of the cultural other (Fassin 2000). Others
(Benslamah 2004; Douville 2014) criticized Nathan’s work while underlining the
need to consider cultural hybridity, intra-cultural contradictions and tensions, and
subjective strategies to adapt to a cultural environment. Still, Nathan’s innovations
have to be understood in the context of a system of mental health care where
specific needs of cultural groups have been mostly ignored.
In the last decades, the passionate debates about Nathan’s ethnopsychiatry have
given way to new approaches where the need to consider cultural diversity is
defended while relying on a dynamic notion of culture that considers cultural
complexity (Hannerz 1992). This reorientation of the French ethnopsychoanalytic
tradition has been tightly linked to the work of Marie Rose Moro and her team
(Moro 2014; Baubet and Moro 2003).
French Intercultural Psychology
Intercultural psychology has developed in France since the 80 s, with Toulouse

being the first faculty to propose a specific training and diploma for intercultural
psychologists. The primary focus of research in French intercultural psychology are
related to cultural contact and change in the context of migration. Claude Clanet,
along with others, criticized the notion of acculturation and introduced alternative
models for cultural change. Clanet (1990) developed a specific interest for the
creative potential of cultural contacts, and introduced the notion of interculturation
in order to describe the creation of new cultural representations and cultural
identities in this context.
The relation between French intercultural psychology and French ethnopsychi-
atry was rather distant in the beginning, as intercultural psychologists criticized
3
With some meritorious exceptions such as (Jusot et al. 2009).
123
essentializing approaches to culture (especially in Nathan’s work). Only recently, a

more intensive dialogue with clinical approaches in the field of transcultural
psychiatry has emerged (Sturm, Guerraoui, and Raynaud 2016). The Intercultural
Consultation Service has been elaborated in the context of this dialogue. The
reflection on cultural contact with the tensions and conflicts it may create, and a
specific interest on processes of interculturation, play a central role in this approach.
Organizational Cultures of Intercultural Health Care for Children

in France
In France, mental health care for children is organized on the basis of a territorial
system. The medical and psychological centres (CMPs) play a central role within
this system. These centres are the gateway to mental health care, proposing cost-free
assessment and treatment. They work in tight cooperation with other mental health
care institutions, child protection services, and schools (Petitjean 2010). The CMPs
also cooperate with private health care providers who play an important
complementary role in service provision. Private mental healthcare is not free,
but it is reimbursed to a high degree (if not completely) by the Social Security and
complementary assistance if needed.4 Still, some of the therapeutic interventions
(such as psychomotor training or psychotherapy) will not be reimbursed if they are
proposed outside of the CMP. This leads to a certain selectiveness in service
provision: low income families (and a high percentage of families with migration
background) will be more likely to use public services, while middle and high
income families often refer to the private sector in order to avoid waiting lists. In
practice, this means that public services take care of a large number of ethnic
minority patients.
However, culturally competent service provision has not yet become a standard
in mental health care for children and adolescents in France. The implementation of
staff training in cultural competencies or the organization of accessible and
reimbursed interpreter services is far from guaranteed. Still, many local initiatives
exist in larger cities which provide training on specific issues linked to migration
and diversity, and culturally informed supervision and/or case studies. Many of the
specific trainings are inspired by the French ethnopsychiatric and ethnopsychoan-
alytic tradition of transcultural psychiatry (Baubet and Moro 2013; Moro 2011).
Others are related to the French tradition of intercultural psychology (Guerraoui and
Pirlot 2011).
A specific challenge is linked to linguistic diversity, and concerns the need to
work with interpreters in situations where the children and/or parents have limited
proficiency in the language of the host country. The work with interpreters not only
requires specific skills and training for interpreters, but also it also requires
expertise, flexibility and an understanding of the specific challenges of interpreting
on the mental health professionals’ part (Leanza et al. 2014). In 2012, a nationwide
4
For a detailed description of the French Helth Care System and Barriers to Access for Migrant
Minorities, see Dourgnon, Sturm and Rietsch (2017).
123
network of French associations providing community interpreting in different

regions along with a certain number of public health services adopted a Charter
defining ethical standards and quality criteria for community interpreting in the
context of health and social care.5 Even though local differences persist in training
and supervision of community interpreting service providers, common standards
include ethical requirements of neutrality, anonymity, and confidentiality. Training
programs include knowledge about French health and social care system, translation
techniques, and issues related to the relational aspects of community interpreting.
Most of the mentioned associations provide formal or informal supervision for the
community interpreters they work with.
A recent study on the use of existing interpreter services in the field of mental
health care in France highlights different barriers to access in practice: lack of
knowledge about existing services, budget problems and ambivalence related to
ethical and political positions with regards to the integration of foreigners, and the
moral judgement that immigrants should be encouraged to speak French (Béal and
Chambon 2015). In addition to these barriers, therapists often feel destabilized by
the complexity of the work with interpreters who may lack skills and training for
this kind of cooperation. Working with interpreters in child mental health care
challenges professionals, especially in family consultations where the interpreter
necessarily becomes part of the system with its relational dynamics. This demands
flexibility and reflexivity on the therapist’s side, as well as the capacity to adapt the
therapeutic setting and intervention techniques to the specific challenges of the work
with an interpreter.
The Local Context: Cultural Diversity in Toulouse
Toulouse, a city of about 450,000 inhabitants, is located in the southwest of France,

not far from the Spanish border. In the first decades of the last century, many
immigrants arrived in this part of France, especially during civil war and
dictatorships in Spain and Italy. Many of these families stayed in the rural regions
close to the Spanish border, and transnational family bonds continue to be
important. From the sixties onward, the immigration from northern Africa,
especially from Algeria, became the most important flow in the region. These
populations concentrated in the urban spaces, especially in Toulouse. More recently,
the Airbus quarters and industrial site in the suburbs of the city attracted highly
qualified professionals from different European countries. In these suburbs,
international schools and other facilities linked to the mobility of these populations
changed the landscape of local life (INSEE 2005).
In the last decades, immigration flows have diversified all over Europe (Rechel
et al. 2013), and new immigrants from countries all over the world arrive in
Toulouse, staying mostly in the urban centre (INSEE 2012). In the context of the
refugee migration wave, new migration flows have been established. Recently,
5
http://www.unaf.fr/IMG/pdf/charte-signee-scan19-12-2012.pdf.
123
migrants from Calais including families with children, and unaccompanied minors
have been relocated in the surroundings of Toulouse.
The Intercultural Consultation at the La Grave Hospital in Toulouse
Aims and Purpose
The Intercultural Consultation (ICS) was designed to improve the delivery of

culturally competent service provisions in public mental health care for children and
families. In 2013, The ICS was integrated into the medical and psychological centre
(CMP) la Grave, which is one of the six CMPs which covers one of three large
catchment areas of the region. Each of the sectors of these six CMPs includes parts
of Toulouse and parts of the larger surrounding region. They are all related to the
University Hospital (CHU de Toulouse) and the Child and Adolescent Psychiatry
Department of Toulouse University (SUPEA). Different therapeutic orientations
coexist in each team of a CMP, (as psychoanalytic, cognitivist and systems therapy
approaches), but they all share a team-centered approach where weekly team-
meetings with case-discussions play a central role.
While the implementation of the ICS is currently restricted to the CMP la Grave,
a closer cooperation with the six other CMPs is in preparation, with an
implementation of an ICS to a second CMP (Ancely) from 2017 on and the
perspective to develop shared case-discussions, trainings and supervisions for all
teams. Over time, there is more cultural diversity in the population that consult at
the CMP. Beyond the more established minorities (as families with migration
histories related to Portugal, Spain, North Africa and the Antilles), more recent
immigration is diversifying. After the dissolution of the transitory camp at Calais,
families from Afghanistan, Syria, and Iraq arrived at the suburbs of Toulouse and
some of them will most certainly consult in the public mental health system.
Cultural complexity (transnational family organizations, multi-lingual families,
being part of one or more minorities) has become part of the ‘‘profiles’’ of many
consulting families.
The ICS is integrated into the CMP la Grave, and it is organized as a
supplementary resource proposing specific interventions in addition to existing
services. One of the therapists (SB) is part of the team of the CMPs La Grave and
Ancely, working as an educator in different settings and participating in all staff-
meetings. She is trained in systems therapy and in clinical transcultural psychiatry.
The other (GS) has experience in clinical work and training in the field of
transcultural psychiatry, trauma therapy and ethnopsychoanalytic work with
children and families. She was engaged in order to help to build up the consultation
service. GS’s involvement with the ICS is on a part time basis, however, she
participates in staff-meetings, case discussions and supervisions.
The objective of the ICS is to be seen on two levels:
– Improvement of service delivery for the consulting families in terms of
therapeutic alliance and outcome.
123
– Training for the team via case discussions during staff meetings and supervisions.
The ICS was created in response to the results of a local research project that
showed that child psychiatrists experienced difficulties in constructing a trusting
relationship and a good working-alliance with some migrant families, especially
those with complex migration backgrounds (Benadiba 2008). It was conceived of as
an adaptation of existing models of cultural consultations in France and Canada
(Measham et al. 2014). The creation and development of the ICS is part of a
cooperation between the University Hospital la Grave and the research team of the
Laboratoire Cliniques Pathologique et Interculturelle (LCPI) at the University of
Toulouse Jean Jaurès.
The Intercultural Consultation: Implementation, Structure

and Therapeutic Techniques
The team of the CMP La Grave includes two child psychiatrists, two psychologists,
an educator, a speech therapist, a psychomotor therapist, a social worker and a
secretary. The team of the CMP La Grave already has some expertise in culturally
sensitive service provision: all team members collectively attended trainings and
case-studies, one psychologist has been trained in intercultural clinical psychology,
and the educator has attended different trainings in Toulouse and Paris. The
psychologist of the ICS is the only team member with migration experience. Other
team members have family histories related to immigration from Spain, Italy and
the Maghreb region. Still, these backgrounds had not been discussed by the team
until a first training with a local association had taken place, some years before the
creation of the ICS. Professionals refer to this training as an important experience,
but still, they barely include a reflection on their own cultural situatedness during
case discussions. This strict separation between professional identity and personal
background mirrors the French Universalist tradition where cultural affiliations are
assigned to the private sphere (Fassin and Rechtman 2005).
The hospital has an interpreter service that provides trained interpreters via
cooperation with a local association, la COFRIMI,6 which is part of the national
network mentioned above.
Referral to the ICS is based on a case discussion in the team meetings, and
requires meeting two conditions:
– Complex migration trajectories or transnational family constellations that seem to
be difficult to explore in common evaluation and therapy settings
– Difficulties in establishing mutual understanding and a solid therapeutic
relationship with child and family in other settings
In many cases, we are asked to help professionals to better understand the family
dynamics and possible obstacles to the therapeutic alliance.
We propose short-term therapies with four sessions that take place once a month.
Other therapeutic propositions as speech therapy or therapeutic groups for the
6
http://www.cofrimi.com/.
123
children continue during the therapy in the ICS. At the end of the therapy
recommendations and insights are presented during the weekly team meetings.
The Intercultural Consultations are scheduled for about 90 min although they can
take up to 2 h. If an interpreter is present, our procedure is very similar to the
guidelines formulated by Leanza et al. (2014):
– A first contact with the interpreter is established prior to the first interview with
the family in order to explain our way of working, specific challenges linked to
the family setting, and our expectations for the cooperation with the interpreter.
We also agree on nonverbal signs the interpreter may show if a situation is too
difficult to handle. Additionally, we discuss the specific difficulties/challenges
after the interview. Ethical standards and the engagement to follow the Charter
for Interpreters are also addressed at this occasion.
– At the beginning of the interview the interpreter is introduced the confidentiality
requirement is explicitly addressed. When family members speak in French, we
remind them that they may or may not use the interpreter during the session, and
that they can switch languages, according to their preference. The interpreter is
asked to give close-to-the-text translations. Short comments concerning difficul-
ties of translation (plurivalent expressions, specific connotations or literal
translations of common expressions) can be given during the interview. Other
comments such as context information, global impressions, interpretations or
emotional reactions are discussed after the consultation. We do not ask the
interpreter to do cultural broking during the therapy session.
– After the therapy session, we have a 5–10 min discussion with the interpreter.
Difficulties in translation or in the relational constellation are addressed at this
occasion. Sometimes interpreters bring up important context information during
this discussion. If this is the case, the subject is brought up and discussed with the
family during the following session. Usually we work with the same interpreter
throughout the therapy.
In terms of therapeutic orientations, our approach integrates aspects of systemic
family therapy, psychoanalytic work, cultural mediation techniques and ethnopsy-
choanalytic therapy in the tradition of Moro’s work. Family dynamics are
questioned while relying on a dynamic and self-reflecting perspective on the
interaction between therapists and families, including enactments of cultural
proximity and difference (Falicov 2011; Sluzki 2015). Acculturation strategies and
creative ways to combine and transform cultural meanings and practices are
important topics. These processes are understood as transformative practices,
leading to new cultural meanings and identities. We use concept of interculturation
(Clanet 1990; Denoux 1994; Guerraoui 2009) to describe the dynamics of these
processes. Mediation is proposed on the basis of a dynamic understanding of
intercultural relations and with a specific interest for the power-dynamics occurring
in the interaction between families and institutions (Rousseau 2003). In this context
we try to understand misunderstandings and conflicts between the family’s position
and institutional procedures with their underlying ‘‘cultures of care’’ (Ascoli et al.
2012). Psychoanalytic thinking is mainly used in order to reflect on family dynamics
and the dynamics occurring between family members, therapists and the interpreter
123
during the therapy session. This also includes a reflection on the dynamics between
transference and counter-transference which is discussed during supervision.
Psychoanalytic (Garland 1998; Lebigot 2005) and ethnopsychoanalytic (Mouche-
nik, Baubet, and Moro 2012; Sturm, Moro, and Baubet 2010) thinking also play a
central role in our clinical reflection on trauma. However, we do not try to determine
the psychic structure of the child or other family members in these consultations, or
provide interpretations in this sense.
Content and Process of the Work in the Intercultural Consultation
Content and process of the work in the Intercultural Consultation is variable and
adapted to the specific situations we encounter. Still, some central points are
regularly discussed:
– Different perspectives on ‘‘the problem’’ of the child. We confront ‘‘family
perspectives’’ with different ‘‘professional perspectives’’ the family has encoun-
tered, while discussing underlying logics and inherent contradictions.
– The construction of a narrative about the migration and a discussion about
transnational family bonds. We usually work on a genogram (a graphic
representation of the extended family). Often, this is the first occasion for the
children to hear narratives about difficult or traumatic moments related to
migration. Special attention is paid in order to provide a holding and a supportive
attitude during this process, especially when traumatic experiences arise.
– Continuity and change with regards to cultural identities, cultural contact,
acculturation strategies, and the use of different languages in the family. Often we
discover important influences from transnational family networks on different
parts of the globe and complex cultural identities as well. Furthermore, we
discuss social contacts in daily life, the neighborhood, school, and extra-
curricular settings.
– During the last session we discuss what we have learned together, and also what
we should tell the team in terms of insights and needs of the family. This is often
a moment where family members bring up very concrete demands—for example
that they would like to have a member of the team attend to a school meeting or
would like to have an interpreter present in other therapy settings where they have
consulted so far without one. These propositions are discussed in the following
team-meeting.
We always invite the whole family to therapy sessions, with all children present,
and sometimes ask to include other significant family members (such as grand-
parents). The sessions take place in the educator’s office where the children can
either sit with their parents, listen, participate, or draw or play.
After concluding the consultations in the ICS, we document our work in a short
summary including a graphic representation of the genogram. In addition, we started
to use an adaptation of the Cultural Formulation Interview as a tool for a more
detailed documentation and transmission.
The outline for cultural formulation (OCF) is a clinical tool that has been
introduced to the fourth edition of the Diagnostic and Statistical Manual of Mental
123
Disorders DSM-IV (American Psychiatric Association 1994) in order to help

clinicians to explore the cultural dimension of mental disorders.7 It has been further
developed on the basis of this work, which was coordinated by an international
work-group (Lewis-Fernandez et al. 2014), and recently a new version of the
cultural formulation, the cultural formulation interview (CFI), was introduced to the
DSM-V (American Psychiatric Association 2014).
In addition to the guideline of the DSM-V, adaptations to specific clinical
encounters have been introduced and made accessible, as the Guidelines for
Cultural Assessment and Cultural Formulation of the Cultural Consultation Service
at the McGill University in Montreal. The B-Version of this guideline was
conceived for the use of researchers or supervisors, in order to have different
dimensions of culture-relevant information during an interview with clinicians
(Guzder and Rousseau 2016).8
As our project includes a training dimension for staff members and trainee
clinicians, we decided to use the B-Version of the Guideline for the Cultural
Formulation of McGill University in order to document what we learned during the
therapy. As our objective is to complete existing information and observations by
the insights we had during the therapy in the Intercultural Consultation, we only use
the family narrative part of this Guideline. The integration of this specific
information into a global clinical picture takes place during the team-meetings.
In the following section, we present an example of such a Family Narrative. This
narrative will be completed by a process and relation-oriented reflection on the
situational and interactive dimension of the Intercultural Consultation. We would
like to argue that this type of insight is complementary to the more content-oriented
description in the Family Narrative.
Case-study from the Intercultural Consultation9
Jacob came to the CMP for the first time when we was seven years old. He was in
his second year of primary school, and the teachers were concerned because of his
learning difficulties. He still had significant difficulties in reading and almost didn’t
speak at school. He also seemed to be isolated and to have major difficulties
engaging with his peers. The school team had met the parents, organized learning
aids at school and invited the parents to attend an appointment at the CMP.
After a first evaluation at the CMP, Jacob was diagnosed with elective mutism in
the context of acculturation difficulties and problems related to his social
environment. A treatment plan was proposed, combining speech therapy in private
and regular appointments with the psychiatrist for Jacob, his 5 year old sister
Bimala and both parents. The psychiatrist had seen the family several times, but she
7
For a detailed presentation of the cooperation between the DSM-IV taskforce and the group of
specialists in cultural anthropology and cultural psychiatry who participated in the preparation of the
DSM-IV, see (Littlewood 2001; Mezzich et al. 1999).
8
http://www.mcgill.ca/culturalconsultation/handbook/assessment/cfb/.
9
In order to insure anonymity of child and family, names and other information that could lead to their
identification have been changed.
123
explained that the work with the parents had always turned out to be difficult. As
both parents did not speak French very well she worked with an interpreter, but this
cooperation also turned out to be difficult. From the psychiatrist’s point of view, the
interpreter was quite ‘‘cold’’ and seemed almost rejecting. Under these conditions, it
seemed difficult to get a clear picture of the family situation. The therapeutic
alliance was not well established, and many of the psychiatrist appointments were
cancelled. Jacob missed many of his weekly sessions with the speech-therapist.
Nevertheless, he made some progress and started to speak a little bit more at school.
He still had difficulties memorizing and applying what he had learned during the
speech therapy sessions. The speech therapist proposed intensifying the treatment
plan, but the parents did not agree.
At a team meeting with the speech therapist, we decided to propose therapy with
the Intercultural Consultation to the family. We hoped to come to a better
understanding of the social situation of the family, the stressors they were exposed
to, and the history of their migration and transnational bounds. We also hoped to
come to a better understanding of the family dynamics and the context of Jacob’s
difficulties.
Reconstruction of the Family Narrative on the Basis of the Guideline

for Cultural Formulation
Past Medical or Psychiatric History
Both parents had good health before their migration. Since her arrival in France,
Mrs R. has had some somatic problems in which she feels tired and unable to work.
She meets regularly with her general practitioner. She never consulted for
psychiatric problems and did not receive any treatment. Mr R. does not relate
any health problems.
Family History
Mr R. was born in Sri Lanka, as the oldest of four brothers. The family was
dispersed in the context of the civil war, but now his parents and his brothers live in
Jaffna. He is in irregular contact with them. Mr R. does not appear to be at ease
when he talks about his family. Jacob and his sister do not know the members of
their paternal family.
Mrs R. was born in Sri Lanka as the eldest of five children, four girls and one
boy. She had a close, almost maternal relation with her siblings, especially with her
two youngest sisters, one of whom died when Mrs R. was 20 years old.
Mrs R. grew up with her family and lived with them until her migration to
France. Her parents had a small restaurant not far from Jaffna and Mrs R. helped out
in this family enterprise. She had a close relationship with her father. Mrs R. does
not mention any conflicts with her mother, but she seems to be uneasy when talking
about her. This behavior contrasts with the emotional way she talks about her father.
Two of her sisters and one of her brothers live in Europe. She is in regular contact
with them via phone and skype. Mrs R. is very attached to her youngest sister who
123
still lives with her parents in Sri Lanka. They regularly talk, and Mrs R. would love
to see her.
Mr and Mrs R. met in Lyon. They did not know each other before their migration.
Their families were not in contact before they learned about the marriage plans of
Mr and Mrs R., but both sides gave their consent to the marriage. Mrs R. was in her
mid-twenties, Mr R. a little bit older. Neither of them talks about previous
engagements.
Jacob was born in France. His name had been chosen by his parents ‘‘because it is
a Christian name’’. While both parents are Christians Mr. R is Catholic and Mrs R.
is Protestant. They emphasize that this difference is not important to them and that it
did not cause any problems between their families. Bimala was born two years after
her brother. Mrs R. had given her the name of the younger sister she had lost some
years before in order to ‘‘remember her’’.
The children have regular contact with their uncles, aunts and cousins who live in
Germany and in Switzerland. One of the sisters of Mrs R. came to visit the R. family
with her husband and children during the period they were in treatment with us.
Together, they went on a pilgrimage to Lourdes.
Migration and Trauma
Mr R. did not talk about the reasons for his migration to France. He obtained the
refugee status soon after his arrival in France. Mr R. does not appear to be
comfortable talking about his past in Sri Lanka. We imagine that he went through
traumatic situations linked to the civil war, but we do not know anything about it.
Mrs R. came to France during the same period. Her father, who wanted to protect
her from the chaotic situation in Sri Lanka, travelled with her. Some of her siblings
were already living in Europe but not in France. Mrs R.’s father stayed with her for
a certain time and also attended the marriage ceremony in Lyon. When Mrs R. was
pregnant with Jacob, the young family decided to migrate to Switzerland in order to
join a sister of Mrs R. Mrs R.’s father travelled with them. When they tried to cross
the border, Mrs R. and her father were arrested because they did not have residence
permits, and both were kept in a detention centre in France for some days. Mrs R.’s
father was deported to Sri Lanka, and Mrs R. was released because she was
pregnant. The detention, the separation from her husband, the deportation of her
father, and her fear to be deported at any time had a visibly traumatic impact on Mrs
R., and she is still confused and panicked when she talks about these events.
Child’s Developmental History10
Mr and Mrs R. do not relate any particular developmental problems for Jacob or his
sister. When discussing their perception of Jacob’s problems, Mr R. appears to
avoid and underplay Jacob’s difficulties, and make a point of his capacities to talk in
Tamil and English. Mrs R. appears to be rather concerned, and, it would seem, feels
10
This part only describes information from the ICS. More detailed information concerning
developmental steps was taken during the evaluation by the child psychiatrist.
123
guilty and responsible for her son’s problems because of her own problems with
integration and language acquisition.
Social Setting in France
Mr and Mrs R. live with their children in a tiny apartment in Toulouse. They have
limited financial resources. Mrs R. does not work because she does not have a work
permit and also ‘‘because of her health’’. Mr R. has gone through long periods of
unemployment. During the treatment in the Intercultural Consultation, he found a
job which helped to ease the financial situation of the family. Mrs R. seems to be
very isolated from outside contacts. She avoids leaving the house more than
necessary out of fear of being arrested, because she still does not have a residence
permit.
Neither child sees any friends outside of school. At the beginning of our
treatment the children did not remain at school for any extra-school activities, and
they went home to eat with their mother at lunch break. During a joint school
meeting, which the social worker of our team attended, the parents were encouraged
to let their children participate in extracurricular activities in order to help them to
integrate to their group of peers and to facilitate acquisition of the French language.
After the meeting, Mrs R. decided to let her children stay twice a week for some
time after school. Mr and Mrs R. also decided to bring Jacob twice a week to speech
therapy, and engaged a Tamil student to help Jacob with his homework. Both
children visibly enjoy these visits.
The most salient contrast to life in Sri Lanka for Mrs R. is the lack of social
contact and support. As Mr R. did not talk very much about his past, we do not
know very much about his perception of the differences between the contexts. Still,
he agrees that they are facing significant social and economic problems and that
they have limited social contacts in France.
Mrs R. seems to be the one who mostly manages the social life of the family. She
maintains regular contacts with her family members in Europe and in Sri Lanka. She
also accompanies the children to school and to their appointments (e.g. the speech
therapy). Mrs R. sometimes attends services at a protestant church with other
Tamils.
The children meet children from the host culture at school and more recently at
out-of-school activities. Still, they do not have close friends; they do not invite
classmates over to their house nor are they invited by their classmates either.
The contact with Mrs R.’s family, especially with those living in Europe, appears
to be an important resource for the family that helps overcome their isolation to
some extent.
After the first Intercultural Consultation, we organized an appointment with our
social worker for Mrs R., with the assistance of the interpreter. In the following
weeks, Mrs R. established a strong and trusting relationship with the social worker
who initiated home visits in order to support the family. At these occasions, she
could observe that the family was living in poor economic conditions but they
created a warm and welcoming atmosphere in their home.
123
Cultural Identity in France
All family members speak Tamil fluently. Mr R. also speaks English fluently. Both
parents understand and speak French, but Mrs R. encounters difficulties expressing
herself well in French. She is able to read and understand almost everything, but she
feels shy and does not try to speak.
The children mostly speak Tamil with each other. Sometimes they switch to
French but only occasionally. All members of the extended family in Europe speak
Tamil, and the children do not have any problems communicating with their cousins
in this language. Both children started to learn French in pre-school. During our
consultations, they speak spontaneously in French to us and in Tamil to the
interpreter. Both parents identify as Tamil, but they have few Tamil friends in
Toulouse.
Psychosocial Environment and Levels of Functioning
The most important social stressor for the family is their economic situation and
legal migration status. As Mrs R. does not have a residence permit, she is afraid
that she might be deported, and she cannot leave French territory without taking
the risk of being unable to return to France. She could apply for a permit for
health or humanitarian reasons, but she would also assume the risk of a negative
answer followed by an invitation to leave French territory. This situation paralyzes
the whole family. For Mr R., the most important stressor is the economic situation
of the family and the difficulty to find stable work that pays for the needs of the
family.
The most important sources of support appear to be Mrs R.’s extended family.
Another important resource is a social worker from the city who has regularly
helped the family with administrative issues. For the children, contact with other
children in school and extra-curricular activities are an important resource,
especially for their socialization and integration.
Comment on the Family Narrative
The four sessions in the Intercultural Consultation helped us to get a more complete
and less confusing idea of the situation of Jacob’s family. Primary stressors, such as
the family’s social and administrative situation, appeared clear, but so did
vulnerabilities linked to prior experiences, such as the traumatic experience of the
detention during pregnancy for Mrs R. We also discovered important social
resources such as the extended family network in Europe, or the regular contact with
the maternal family. The question of language learning proved to be a problem not
only for Jacob, but also for his mother. Her restricted language proficiency also
limited the possibilities to communicate with the school team.
123
The Process of the Intercultural Consultation: Tensions and Insights
The picture of what we learned about the family would be incomplete if we did not
talk about what we learned through the process and the relational dimension of the
Intercultural Consultation. In the following, we would like to add a description of
these aspects, starting with the dynamics confusion, fright and discomfort which
characterized the beginning of our encounters, and concluding with the dynamics
that led to the creation of new therapeutic spaces.
Confusion, Fright and Discomfort
When we first heard about the R. family, there seemed to be a lot of confusion
among the whole team. Professionals were concerned about Jacob’s difficulties and
stressed the need to intensify the treatment plan but felt helpless while facing the
discontinuities provoked by cancelled consultations. The team knew that the family
was in a difficult social situation, but as the social worker of the team was not yet
involved in the treatment, nobody seemed to have a clear picture of the economic
and administrative problems the family was facing. The situation was worsened by
the difficulties the psychiatrist encountered when working with the community
interpreter, whom she experienced as ‘‘cold and distant’’.
Evidently we saw the need to clarify the situation with the help of the social
worker of the CMP (which is a standard procedure in the CMP), but we also
perceived a dynamic of confusion in a situation where urgent need to intervene
contrasted with the feeling of being paralyzed and unable to bring change. We think
that the feelings of helplessness that seemed to paralyze the team were caused by the
panic and confusion Mrs R. experienced, on the basis of a very concrete fear of
deportation, but also on the basis of a constant reactivation of the traumatic
experiences she made during the detention. The encounter with severely trauma-
tized people can typically provoke feelings of helplessness and confusion in
professionals (Garland 1998). This is why we prepared ourselves for a consultation
that could possibly be characterized by the dynamics of trauma. The construction of
a secure environment seemed crucial.
The Construction of a Secure Environment
During our meeting with the interpreter before the first consultation, we discussed
specific difficulties an interpreter may face when working with trauma. She already
knew the family, as she had worked with the child psychiatrist. She was very
affected by their suffering and her seemingly cold attitude was caused by her
tentative to control her feelings of helplessness. She was visibly comforted
especially when we explained that her feelings of helplessness were normal
reactions to the dynamics of trauma and not the result of any ‘‘technical errors’’ on
her side.
This preliminary discussion was of great help for the establishment of a
relationship with the family. The interpreter was reassured and this helped us build a
warm and inviting atmosphere. During this first encounter, Mrs R. talked about the
123
loss of her younger sister; crying sadly, and allowing us to share in her pain. The
children looked at their mother and approached her, but they did not show any signs
of fear or confusion. It was evident that they felt we were there to help their mother
to face her sadness. During this session, Mrs R. also talked about the traumatic
experience of her detention and the deportation of her father.
Unfreezing
During our second meeting, Mrs R. seemed to be much more reassured and self-
confident. She talked about her wish to travel with the children to Sri Lanka.
Apparently, they had started to talk about this idea in the family and the children
told us that they would love to meet their grandparents and see the country of their
parents. Mrs R. was wondering if she could take the risk to leave French territory in
order to travel to Sri Lanka and try to enter with a tourist visa on her way back. We
encouraged her to obtain information which she decided to do. She also told us why
they wanted to travel to Sri Lanka: her younger sister was going to get her doctorate
degree, and she wanted to be with her to share this important moment. After
obtaining further information, Mrs R. finally decided not to take any risks of being
separated from her family if ever she were to be unable to return from a travel to Sri
Lanka, but still she seemed less sad about it. She was in regular contact via phone
and skype with her sister and found a way to be close to her while being
geographically distant.
Differentiation of Identities
The question of differentiation, individuation and the development of a flexible,

multi-referential and yet solidly based identity seemed to be an important subject for
all family members. For the children, this issue was closely linked to age-related
processes of separation and the development of autonomy.
At the beginning of the first session, both children sat down at a little table we had
prepared for them and immediately started to draw. Jacob was drawing a boat and a
car, and was writing his name on a paper, decorated with many little stars around. His
sister, astonishingly skilled, was drawing similar things as her brother and was
imitating his style. Jacob seemed to be slightly irritated by his sister. During the next
session, Jacob started to draw the hello-kitty cat decoration on the t-shirt of his sister,
which she visibly disliked. They started to kick each other under the table and Mrs R.
told us that they were constantly quarrelling at home. It was visibly hard for both of
them to separate and differentiate if it was not through conflict, in the therapy session
as probably in daily life, where the two of them spent so much time together. Fright
and withdrawal had paralyzed and isolated the family, and under these conditions it
was difficult for the children to engage in an age-related separation process. This
situation gradually changed when the children had more extra-school contact with
other children. The regular visits of the Tamil student who came to help Jacob with his
homework were also of great help. He was a new role-model, a young man, visibly
successful and not frightened at all by the French language, coming to the family’s
home and helping Jacob bridge the gap between family life and school.
123
The question of difference and the possibilities to create a unique but still plural
and open identity also appeared in our exchanges with the parents, especially with
Mrs R. Interestingly, these issues came up when Mrs R. was showing her interest in
our cultural and religious affiliations.
During our first encounter, Mr and Mrs R. had told us that they were ‘‘both
Christians’’, even though Mr R. was Catholic while Mrs R. was Protestant. As we
had been informed by the interpreter that conflicts between Catholic and Protestant
families were rather common in Sri Lanka, we decided to come back to the question
of religion once we knew the family better. Finally, we discussed this issue during
the fourth visit when we met Mrs R. and her children without her husband (who was
at work) and without the interpreter (who wasn’t able to attend the consultation). It
was just before the Easter holidays, and we were asking Mrs R. how they would
celebrate Easter at home. She explained that she would prepare a feast and go to
church with the children.
At that moment, we decided to enact cultural and religious diversity, relying on
our own cultural affiliations (French and German, with Catholic, Protestant and
convinced atheist heritages in both families). We talked about the historical tensions
between Catholics and Protestants in Europe, but also about the pragmatic
arrangements families made in order to integrate different religious and atheist
affiliations without conflict. Mrs R. seemed curious and also a little bit surprised
about the cultural complexities we tried to enact.
We continued with a discussion about different Easter traditions in France and
Germany. At that moment, the children started to participate, rather vividly, and
defended the cultural practice of hiding chocolate eggs (versus hen’s eggs as it is
often done in Germany). The children immediately tried to convince their mother to
participate in the French tradition of hiding chocolate eggs. The situation became
playful, and Mrs R. seemed to be amused by her children’s engagement.
We think that this session was important for Mrs R. and her children, indicating
possibilities to overcome binary perceptions of ‘‘us’’ and ‘‘them’’ through a playful
interaction where curiosity and cultural hybridity were welcomed. Mirroring
familiar diversity in the family (Protestant and Catholic traditions, cultural traditions
of the French environment of the children and the German environment of their
cousins) helped to open new possibilities to create and integrate cultural complexity
without feeling in danger.
New Therapeutic Spaces
After concluding the five sessions of the Intercultural Consultation (we had added
one session because we wanted to close the therapy with the interpreter), we
discussed the situation of Jacob’s family with the team. As Jacob’s problems
seemed to be at least partly linked to a family dynamic that was characterized by
withdrawal and lack of differentiation, the team decided to propose two (different!)
therapeutic groups for the children in order to help them to express themselves, to
engage with other children and to engage in a process of separation and
differentiation. We also talked about the possibility of Ms R attending French
classes close to their home. We also mentioned Mrs R.’s vulnerability and the
123
traumatic dimension of her social withdrawal. The child psychiatrist later discussed
this issue with her during an individual appointment and indicated possibilities to
get access to evaluation and treatment.
The family accepted the therapeutic suggestions for the children. Both children
started treatment in a therapeutic group working with creative expression
techniques, and the psychiatrist worked with Jacob’s sister in order to evaluate
further needs. Mrs R., who took up the suggestion of treatment, explained that she
would like to have psychotherapy, but with an interpreter. The social worker of our
team helped her to find a treatment.
Comment on the Process of the Intercultural Consultation
Although the content-oriented presentation helped us to organize the information we

gathered during the treatment, it seemed necessary to us to discuss the process and
relational dimensions of our encounters, in order to better understand how
representations of self and other and the intercultural relationship between family
members, therapists and the interpreter developed over time. Key moments of the
therapy, such as the construction of a narrative about the traumatic experience of the
detention or the playful exchanges about cultural practices in France and Germany,
can only be understood when they are contextualized in the relational constellations
in which they occur.
A process and relation oriented documentation helps to contextualize narratives
and to avoid the pitfalls of simplifying or essentializing the cultural dimension. The
way family members talk about their cultural affiliations and identity may change
their way of perceiving ‘‘the problem’’. As Aggarwal (2012) underlines in a
discussion of the Outline for a Cultural Formulation, cultural explanations can
change over time, and sometimes the conditions and the form of these changes can
be extremely interesting for the clinician.
Discussion
In the case study we have an example of a family who has been strongly
destabilized by multiple stressors and adversities. Different disadvantaging factors
(poor housing conditions, limited language proficiency for both parents, and non-
regularized legal migration status for Mrs R. with the constant threat of being
deported) interact with clinical dynamics related to the traumatic experience of
detention for Mrs R. In this case, intersectionality, as the interaction of different
disadvantaging factors, reinforced helplessness and retreat while limiting access to
social support and community bounds. Still, the family maintained a strong
cohesion, a certain degree of social functioning. The parents cooperated with school
and health care institutions in order to get support, even though this cooperation was
not stable and often interrupted.
The family certainly showed resilience in the confrontation with an extremely
adverse situation, at least if resilience is defined from a constructivist and not norm-
orientated perspective. In this sense, Unger defines resilience as ‘‘the capacity of
123
individuals to navigate their way to health-sustaining resources, … and a condition

of the individual’s family, community and culture to provide these health resources
and experiences in culturally meaningful ways’’ (Unger 2008:225). Referring to
Unger’s description of varied patterns of resilience in families (Unger 2015), we
could describe the R. family’s pattern of resilience as avoidant—the confrontation
with main stressors is avoided (via social retreat), but at a huge price in terms of
access to social and institutional support and with a severe impact on the
developmental opportunities for the children.
The Intercultural Consultation team intervened in order to promote mutual
understanding between the team of the CMP and the family, to understand existing
social resources and to get a more global picture of the social and professional
networks that could be supportive for the family.
Furthermore, we tried to enhance change to less costly and more adapted patterns
of resilience, in the sense of recovery, minimal impact or even post-traumatic
growth (Unger 2015). We could not relieve the family from main stressors linked to
their administrative situation. Still, we were able to valorize existing systems of
social support (the extended family network) and improve the quality and
acceptability of institutional support (via home visits and better communication).
This not only created a more trusting relationship, but also helped the family to
accept therapeutic proposals, and develop their own resources; for example,
engaging the Tamil student for homework tutoring.
During our encounters, the family visibly developed a certain number of
competencies in different fields that Sleijpen et al. described in a meta-analysis of
qualitative studies on resilience: looking for social support, developing new
acculturation strategies, adapting educational styles, relying on religion, avoiding
stressors and developing hope (Sleijpen et al. 2015). The family began to more
actively rely on institutional help for social support, they developed new
acculturation strategies (engaging the Tamil student, trying to find close-by
language classes for Mrs R.), they continued to use avoidance to a certain degree
(avoiding the risk to be separated if they travelled to Sri Lanka) and, most
importantly, we think, they started to develop trust and hope for the future.
Conclusion
The current situation in France and in Europe confronts mental health professionals
with an increasing number of children with often complex, or even traumatic,
migration experiences and family dynamics which are affected by the vicissitudes of
the migration and integration process. Mental Health professionals need compe-
tencies and skills to confront these complexities while helping the children to get
access to adapted services.
The Intercultural Consultation Service (ICS) addresses this need via a
combination of short-term interventions and team training through shared case
discussions within a well-established first line institution of mental health care
provision in France, the CMP. The tight cooperation with professionals during the
team-meetings opens interesting perspectives. As the members of the CSI regularly
123
assist at these meetings, and not just when discussing the families we meet in the
ICS, we could observe a shift towards a more culture sensitive attitude in the
discussion about all families (i.e. bringing up questions linked to plurilingual
environment, reflecting on possible support for a child while considering
transnational family organisation etc.).
Therapeutic strategies used in the ICS include an exploration of cultural
complexities related to cultural environments of hyperdiversity (Hannah 2011).
They also include a consideration of different stressors related to migration and
cultural affiliations and a discussion about intersectionality as the interaction
between different disadvantaging factors related to discrimination (Crenshaw 1989).
A key-feature of our work is related to the mobilization of resources of the family
through discussions about their social environment in the present and in the past and
a special interest in transnational family bounds. Other important aspects are the co-
construction of a narrative about the migration experience with the help of the
genogram and a playful enactment of cultural differences and the possibilities to
overcome them through processes of interculturation (Denoux 1994).
In a qualitative evaluation of the experience with the consultation during the last
three years, team members underlined its usefulness for their work. Child therapists
reported that children who participated in the ICS seemed to construct clearer
representations of their family history and their own identity. The social worker
explained that the ICS was helpful for her because the team would more easily
understand the entanglement of cultural, social and administrational factors.
According to her, team members had gained in ‘‘social sensitivity’’.
Acknowledgements We thank the team of the CMP for our close and stimulating cooperation, and give a
special thanks to all families who shared trust, scepticism and many insights with us. Thank you also to
Mme Nasr, Vice President of the DRCI (Head Office of Research and Innovation of the CHU Toulouse),
for having kindly informed us about the legal framework concerning the publication of case-studies in
France: in application of the loi Jardé, the Institutional Review Board does not need to intervene. We also
thank Adil Qureshi and Emily Anne Shults for their careful reading and the inspiring comments.
Compliance with Ethical Standards
Conflict of interest On behalf of all authors, the corresponding author states that there is no conflict of
interest.
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Cult Med Psychiatry (2017) 41:630–655

CLINICAL CASE STUDY

Cultural Sensitive Care Provision in a Public Child

Gesine Sturm1,2 • Sylvie Bonnet2 •

Published online: 2 May 2017

& Gesine Sturm

Keywords Culturally sensitive child mental health Hyperdiversity

Intercultural Mental Health Care for Children

health care services and to promote resilience through appropriate interventions

Models of Service Provision in Child Mental Health Care for Migrant

Culture and Ethnicity in Intercultural Child Mental Health Care:

On a conceptual level, growing diversity, increasingly complex migration patterns

Considering Culture in French Mental Health Care

French Intercultural Psychology

Intercultural psychology has developed in France since the 80 s, with Toulouse

essentializing approaches to culture (especially in Nathan’s work). Only recently, a

Organizational Cultures of Intercultural Health Care for Children

network of French associations providing community interpreting in different

The Local Context: Cultural Diversity in Toulouse

Toulouse, a city of about 450,000 inhabitants, is located in the southwest of France,

The Intercultural Consultation at the La Grave Hospital in Toulouse

Aims and Purpose

The Intercultural Consultation (ICS) was designed to improve the delivery of

The Intercultural Consultation: Implementation, Structure

Content and Process of the Work in the Intercultural Consultation

Disorders DSM-IV (American Psychiatric Association 1994) in order to help

Case-study from the Intercultural Consultation9

Reconstruction of the Family Narrative on the Basis of the Guideline

Past Medical or Psychiatric History

Migration and Trauma

Child’s Developmental History10

Social Setting in France

Cultural Identity in France

Psychosocial Environment and Levels of Functioning

Comment on the Family Narrative

The Process of the Intercultural Consultation: Tensions and Insights

Confusion, Fright and Discomfort

The Construction of a Secure Environment

The question of differentiation, individuation and the development of a flexible,

New Therapeutic Spaces

Comment on the Process of the Intercultural Consultation

Although the content-oriented presentation helped us to organize the information we

individuals to navigate their way to health-sustaining resources, … and a condition

Compliance with Ethical Standards

Derluyn, Ilse, Eric Broekaert, and Gilberte Schuyten

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