This review includes 32 articles. Table 2 presents the principal characteristics of the services and care described in the articles.
Different types of services developed across the world
The adaptation of mental health care to a context of cultural diversity began in English-speaking countries in the 1970s and in France in the 1980s (12,14). According to Kirmayer (20), the difference in the development of mental health services for immigrant populations is associated with countries' histories and patterns of migration and their citizenship models.
First we find countries such as the United Kingdom and France, which have had substantial immigration from their former colonies. These migrant populations very often faced racism and discrimination on their arrival.
In England, transcultural psychiatry began to develop at the end of the 1970s, with the creation of specialized services for ethnic minorities. Later, professionals were introduced to concepts such as cultural sensitivity, antiracist practices, and misdiagnosis (diagnostic errors due to the failure to take cultural factors into account). Multicultural and multidisciplinary advisory teams appeared, and professionals of varied cultural origins were recruited (12). More recently, the United Kingdom has developed an innovative model: the Cultural Consultation Service (CCS). This is an adaptation of the model developed at McGill University in Canada (and described more fully below), which uses an ethnographic methodology and is based on medical-anthropological knowledge. These departments aim to improve the evaluation, treatment, and outcome of immigrant families. They also seek to act on the structural determinants of inequality in access to mental health care and increase the cultural competence of professionals (17,18). Various practices are therefore recommended without any general consensus around a single model (12).
Some countries, such as the United States, Canada, and Australia, whose populations were shaped by successive waves of migrants, have a multicultural citizenship model. This model promotes the existence of multiple cultural communities within the society. These countries thus tend to recognize cultural diversity and its stakes for health in general. There are also ethnospecific clinics (20).
The United States is a country that was built largely through immigration, but has also been deeply marked by its history of slavery and racism. Despite the existence of policies promoting assimilation, migration flows have led to the preservation of different cultural communities. The development of ethnospecific clinics is a response to this diversity. In these clinics, the professionals know the language and the culture of the community they serve (20,21). Ethnic matching of therapists and patients is also facilitated in general medical care (8,22). The USA is also where ethnopsychiatry and ethnopsychoanalysis were born, after World War II, at the Menninger Clinic (in Kansas until 2002, when it moved to Texas), which used anthropology and clinical practice complementarily and strongly influenced the principal French model (23).
In Canada, cultural identity is considered fairly positively, and the concept of "reasonable accommodation" is relatively widespread. The law encourages pluralism and diversity to preserve the language and culture of ethnic minority groups and to combat racism (20). Cultural psychiatry has attempted to meet the challenges presented by the diversity of the population in general healthcare facilities, beyond the development of ethnospecific services in some cities. At the beginning of the 1990s, combining the Canadian concepts of "multiculturalisme de convivence" (multiculturalism of living together, as opposed to that of dominance) with French ethnopsychoanalytic traditions, several plans for transcultural teams took form in the Montréal region (8,24,25). In 1999, to cope with the limitations of this system, the Cultural Consultation Service (CCS) of McGill University was created. It used a consultation-liaison model, which integrates the medical-anthropological approach and Western mental health care. Families are referred by a professional who considers that cultural factors are compromising the evaluation, treatment, or therapeutic relationship. The CCS, with the aid of interpreters and cultural mediators, assembles the information necessary to understand the patients' narratives. The team then researches and drafts a cultural formulation (Table 1), which is submitted to the referring professional, accompanied by treatment guidelines and possible management strategies (8,26).
In Australia, various services have been developed to meet the needs of ethnic minorities and Indigenous communities. The choice for the Indigenous communities was to give them the control in the development and management of care services. Efforts for migrant families have primarily concentrated on language barriers (20). Accordingly, all states and territories in Australia have transcultural mental health resources, funded by the public healthcare system. They make up the Australian Transcultural Mental Health Network, whose function is to support mental health care nationwide, through research, professional training, and innovation in services. Its objective is to improve the accessibility, quality, and cultural appropriateness of mental health care for migrants. Specific innovations include the creation of jobs such as consultant in ethnic mental health and the recruitment of bilingual staff (16,19,27). Moreover, specialized services have been developed for the treatment of victims of torture and trauma to help refugees (28,29).
Countries that have not traditionally received large populations of migrants are also now attempting to respond to cultural diversity to provide greater social justice and appropriate care for all patients. In particular, the Nordic countries, which have been culturally homogeneous until recently (except for several indigenous minorities) have experienced an increase in the diversity of their populations. In Sweden, Finland, Norway, and Denmark, special focus has been placed on developing services to treat the sequelae of violence and trauma as well as on training in cultural competence in general healthcare facilities. Mental health services specific for indigenous populations have also been set up (5,30–32).
In other European countries, isolated initiatives have been launched to respond to the increase in cultural diversity. Nonetheless no government policies have sought to improve the access of migrant families to mental health care. Italy, Germany, and Spain have set up teams aimed at providing transcultural training for mental health professionals (7,15,33,34). Italy has several transcultural care teams in departments of psychiatry and child psychiatry; not only do they offer consultation-liaison services, but they can conduct psychosocial and psychotherapeutic interventions in the most complex cases (7,15). In particular, Italy has developed cultural mediators, as in Milan (Crinali) (35). Germany and the Netherlands are trying to guarantee greater cultural openness in public mental health facilities (5,36), while in Belgium this initiative depends more on non-profit organizations (9).
The French model: transcultural psychotherapy services, with flexible numbers of therapists involved according to the situation
The French citizenship model tends to minimize the importance of cultural differences in individuals in favor of adherence to the shared values of the Republic. Traditionally, the multiculturalism established in France is one that might be called a multiculturalism "of dominance", in which cultural identity can be expressed in the private sphere but is not recognized or valued in the public sphere. There is a widely shared fear of migrant communities. For the sake of integration, homogenization of these differences is expected in the public space (24,25). Therefore, health care in France is traditionally considered to be addressed to everyone, with no specificity linked to their cultural origins and without any recognition of the obstacles that might prevent patients from having access to these services, which are theoretically available to all.
Nonetheless, French psychiatrists and psychologists who see migrant patients must deal with the limitations of this concept of care. In the 1980s, the first foundations of transcultural psychiatry were laid in France, based on the ethnopsychoanalytic theories developed by Georges Devereux (37). According to Devereux, the basic mechanisms of mental functioning are universal, but the processes of an individual's socialization in their culture of origin must be understood to be able to access this universal dimension, since these cultural processes generate diverse and varied clinical events (10,14). From this paradigm, Tobie Nathan at the Avicenne Public Hospital created an innovative psychotherapeutic framework intended for migrant families: the ethnopsychiatry group. Marie Rose Moro, who became director of the program in 1989, modified some elements to adapt it to the children of migrants (the second generation). She insists on the importance of the process of cultural métissage (hybridization) and of decentering (Table 1) (14). A group of transcultural therapists is a central element of this flexible service offered to families, and its most original aspect. We will therefore analyze it now, noting that it does not summarize the model, which can also work in small groups or on an individual basis (with or without an interpreter).
This group-based model of transcultural service shares the factors common to all therapy, such as the construction of a narrative, the establishment of a therapeutic relationship, and a variety of specific theoretical and methodological factors (38).
Organization of transcultural therapy
Transcultural psychotherapy applies a therapy technique based on two complementary interpretations of symptoms rather than a simultaneous reading. Accordingly, anthropological and clinical psychoanalytic approaches are used. The clinical approaches rest on elements from psychoanalytic parent-children therapy, narrative therapy, and systemic and psychoanalytic family therapy, combined with techniques of cultural mediation (14).
Most often, referrals for transcultural management arise during the treatment of children, when medical, social, educational, or other institutions consider that second-line treatment is needed after the failure of standard management. The indication is stated in terms of the complexity of the situation and of the clinical problem, when the team referring the patient considers a cultural clinical approach necessary. In some cases, these referring teams can be seen in an indirect consultation, that is, without the family, to analyze the interventions and help adapt the care strategies (10,38).
The first consultations are intended to construct the alliance and the treatment plan with the family. Once the plan is constructed, the usual follow-up is then organized in sufficiently long sessions (around 90 minutes), scheduled every 6-8 weeks.
Patients are invited to bring their families to these consultations. They are received by a group composed of several therapists of diverse cultural origins and an interpreter-cultural mediator of the same culture as the family, who can interpret successively in both directions (patient-therapist or therapist-patient). At least one professional from the referring team, who is managing and knows the patient, is also invited.
The group is multicultural and multilingual. It is directed by a principal therapist and relies on the trained co-therapists. For the management of children, one of the co-therapists becomes the auxiliary co-therapist for the child, by sitting down to play with him or her, in an area set up for this in the center of the group, with a table, crayons, and games to play. The group represents and embodies otherness and makes it possible to transform this otherness into a therapeutic lever. It thus serves as a support for psychological construction (39). The framework of the group functions as a transitional space in the sense used by Winnicott: a space for listening and receiving, enabling patients to talk about their cultural representations, protected from criticism and lack of understanding. The group holds the family and the child — in Winnicott's sense of "holding" (40). It becomes a transitional space: in the face of the cleavage of migration, the group is a mediator that makes it possible to integrate the culture of origin and that of the host country (14). Finally, management by a group is congruent with the collective approach to care found in traditional societies (8,14,39,41).
The transcultural consultation is a flexible system, and the size of the group can be adapted to the situation. The classic large group includes around 10 co-therapists, as well as trainees. Over the years, the transcultural framework has progressively dealt with new domains, including questions of intergenerational transmission, family dynamics, and child development in the context of migration and even adoption (14,42). The referrals of unaccompanied minors or patients needing specific work around psychological trauma has required some modifications in the size of the group or the function of the co-therapists (10). Experiments with smaller groups have also been proposed according to the family's cultural origin, when large groups have no particular anthropological interest (in families from Southeast Asia, for example), contrary to the families from North Africa and West Africa, who accounted for most families at the time the group system was created and for whom the group has a protective valence that facilitates expression.
The presence of the interpreter is a key parameter in transcultural work, both at the linguistic level (understanding one another) and the symbolic level (recognizing the identity and singularity of the other). The interpreter enables each family member to speak their own native tongue and to recognize its value to themselves and their children, an element that facilitates the construction of their identity (38,43). It has been shown that this interpreter has a function as much for second generation children, speaking French, as for the first generation (43).
The objective of transcultural therapy is to promote a creative dialogue and a co-construction of personal and family narratives that lean on the representations and experiences of the patients, whether they are individuals, families, or collective groups. The principal therapist gives the floor to participants and is always the person addressed. This mode of communication, which anthropologists call indirect, enables great emotional containment. During the sessions, the co-therapists speak at the principal therapist's request to propose their hypotheses, representations, or images, relying on their own attachments, history, and culture. They may evoke myths, history, traditions, etc. These references to personal experience open the door to a dialogue about cultural complexity and the different readings possible in situations of cultural métissage (hybridization) (10,14,38).
On this basis, the group enables the formulation of different conceptions of reality and of what the patient and the family are experiencing. It makes it possible to open the discussion to various — and sometimes divergent — daily realities. This hetero-narrativity of the group authorizes and supports the family members' self-narrativity. The group accompanies them in a reflexive process in which they can question themselves and transform their subjective representations. Each can thus attain a more flexible and complex self-identification and use all of their skills to find new ways of resolving their conflicts (10,14,38,42).
Finally, the framework enables the emergence of narratives that are difficult to share in the framework of individual therapy. These narratives deal, for example, with migration experiences, questions about cultural métissage, and transmission, but also etiological theories about the origin of both the disease and the distress (10) (Table 1). The etiological theories can thus serve as cultural containers that make it possible to ascribe a meaning to the symptoms and to the psychological distress.
The transcultural group opposes an ethnocentric perspective and promotes transcultural encounters. The viewpoint proposed is that of the wealth and multiplicity that results from situations of métissage. It thus becomes a space where the dominant cultural discourse can be questioned, with the suspension of the psychiatric diagnosis performed from western classifications (14,42).
The process of decentering is essential to allow this encounter. One of its techniques involves the analysis of cultural countertransference, defined as therapists' explicit and implicit emotional reactions to the otherness of a patient who belongs to a different culture. Therapists try to be aware of these reactions, most often during work with the group, both before and after the consultation (10,14,39,42). This can also take place later, as part of group seminars where they try to describe and then analyze this cultural countertransference.