Designing culturally competent services for war-exposed immigrants and refugees

Research Snapshot

What you need to know

two women wearing head scarvesService providers working with immigrants and refugees need to be aware of the unique challenges in delivering care to this population and incorporate culturally competent approaches. Best practices for delivering effective mental health services include shifting from a focus on trauma and PTSD to resettlement, using cultural formulation in the DSM, and the use of culture brokers and interpreters.

In our latest Research Snapshot, EENet's Rebecca Phillips Konigs looks at the article, “Recommendations for Canadian Mental Health Practitioners Working with War-Exposed Immigrants and Refugees,” published in the Canadian Journal of Community Mental Health November 8, 2017. Research Snapshots are brief, clear language summaries of research articles, presented in a user-friendly format.

Read it below or download the PDF.

What is this research about?

Immigrants and refugees need to have mental health services that are culturally appropriate to promote their mental well-being. Many immigrants and refugees experienced political violence and war before arriving in Canada. Cultural competency is the set of behaviours or policies that allow people, agencies, or systems to work effectively with culturally diverse populations. Research on the best way to provide culturally competent care for immigrants and refugees is in its early stages.

What did the researchers do?

This article summarizes current knowledge on how to identify and treat mental health problems in immigrants and refugees who have been exposed to political violence and war.  It also offers recommendations for mental health service providers on how to improve the ways they work with this population.

What did the researchers find?

The authors point to current best practices, which suggest moving beyond a focus on post-traumatic stress disorder (PTSD), to understanding the complexities of mental health after resettlement in Canada. They suggest using a tool called “cultural formulation” during assessment to help collect and organize information that is culturally relevant. Using interpreters and culture brokers to bridge the gap between service providers and their immigrant or refugee clients may also enhance cultural awareness.

The authors note that service providers may underestimate the resilience of immigrants and refugees, and only focus on symptoms of PTSD. An overemphasis on trauma may lead some clinicians to mistakenly attribute mental health concerns to events that happened before resettlement and may keep them from recognizing more pressing mental health issues, such as anxiety.

How can you use this research?

The authors offer the following recommendations to service providers:

1. Incorporate the social determinants of health into assessment and treatment.

2. Avoid exclusively focusing on trauma.

3. Use the cultural formulation tool and guidelines in the DSM.

4. Mandate cultural formulation training for professionals and students in psychology/psychiatry.

5. Understand evidence-based practices, including using cultural formulation, working with interpreters or culture brokers, and increasing time with clients.

6. Mandate training for clinicians on the appropriate use of culture brokers and interpreters.

7. Stay updated on current knowledge in the field.

Limitations and next steps

More research is needed on the differences between refugees still living in conflict zones and those who have resettled in the West. Research studies that incorporate culturally diverse values and voices, especially those from war-torn countries, are also needed.

About the researchers

Pushpa Kanagaratnam1,2,3, Clare Pain1,4, Kwame McKenzie1, Nelani Ratnalingam, and Brenda Toner1

1 Department of Psychiatry, University of Toronto, Toronto, ON

2 Centre for Addiction and Mental Health, Toronto, ON

3 Psychological Recovery Clinic, Toronto, ON

4 Mount Sinai Hospital, Toronto, ON


Mental health, war, clinical practice, immigrants and refugees, recommendations

This Research Snapshot is based on the article, “Recommendations for Canadian Mental Health Practitioners Working with War-Exposed Immigrants and Refugees,” published in the Canadian Journal of Community Mental Health, on the web November 8, 2017.

This Research Snapshot responds to the need for evidence related to “how to provide core services that are accessible, culturally safe, and trauma-informed.” This need was identified during dialogues for EENet’s Sharing Together initiative and falls under Evidence Priority 4: “Culturally competent and culturally safe care that reflects cultural knowledge.” To learn more about Sharing Together, which resulted in an evidence priority agenda for Ontario’s mental health, substance use, and addictions system, visit This summary was written by Rebecca Phillips Konigs.