Diversity & Equality in Health and Care Open Access

Keywords

Multiracial identity; Mental health; Cultural safety

According to the Mental Health Commission of Canada “people who are immigrants, refugees, members of ethnocultural groups or who are likely to be racialized (that is, to have others make assumptions about them based on perceptions about race) face particular challenges that put their mental health at greater risk". Among this group is an under-recognized and growing population of people who identify with more than one racial group, also known as multiracials. In the 2006 census, 458, 240 Canadians reported belonging to more than one population group, a 25% increase from 2001 [1].

Although little Canadian research has explored multiraciality, American and British research demonstrates that there are differences in the health of multiracials when compared to other groups [2-5]. Large scale American studies analyzing youth health data have found multiracial youth at higher risk of health and behavioral problems, including substance use, and that those youth had poorer general health and school experiences [3]. Multiracial adolescents report lower levels of emotional wellbeing than their white peers, including higher rates of depression and odds of considering suicide in Schlabach’s study [2]. In another study, multiracial adolescents were more likely to report depression symptoms, suicide ideation, suicide planning and suicide attempts in the past year compared to White and Black youth [4]. Wu et al. (2013) found multiracial Americans had higher rates of mood disorders than Pacific Islanders and Asian Americans and higher rates of adjustment disorder diagnosis among multiracial Americans (23.2%) as compared to 7.3% of Whites and 7% of Blacks [6]. Yet in other studies, multiracials had similar outcomes on measures of wellbeing to other ethnic minority groups, except for White- American Indians, who fared worse than both American Indians and Whites [7,8].

Research on substance use patterns among multiracials reveal further interesting findings. Wu et al. (2003), analyzed data from the largest psychiatric medical data system in the US [6]. Wu et al., found mixed race Americans had “alarmingly” high rates of drug use and higher rates of drug use for any drug compared to Whites, especially for marijuana [9]. Multiracial adolescents had higher rates of substance use than some other groups in the US and earlier ages of initiation [10]. Findings are also varied across multiracial groups. For example, White-Asian youth were shown, first, to have initiated marijuana use and alcohol use earlier than Whites and second, to have engaged in all forms of substance use earlier than Asians [10]. A different study [11] found that Multiracial Hispanics have higher substance use rates than monoracial Hispanics.

Multiracial individuals can experience microaggressions within the family setting encompassing isolation, rejection, favoritism, questioning of authenticity, denial of multiracial identity, and feelings of loss about not learning from family heritage or culture [12]. Multiracials have also been found to have higher risks of child maltreatment and involvement in the child welfare system [13]. In Lorenzo-Blanco, Bares, & Jorge-Delva’s study multiracial youth reported feeling less supported by parents and reported less satisfactory parent-adolescent relationships than was the case with monoracial youth [14]. The same study found that multiracial individuals may experience identity invalidation from family, peers, health providers, and the public. This occurs when their chosen identity is not accepted or doubted by those around them. Rockquemore used the term “systematic invalidation” to refer to the cumulative impact that consistent denial by others of chosen identity may have on mixed race individuals [15]. Double rejection may occur where racism and rejection experienced by multiracials from both or all their identity groups [8]. Similarly, the absence of a natural peer group has been identified as a stressor for both adolescent and older adult multiracials [4,16].

Processes of racialization affect multiracials in complex and sometimes conflicting ways. Physical traits such as skin colour, hair texture and colour, and stature all play a role in contributing both to multi-racial individuals’ self-image and others’ response to them [17]. Siddiqui [17] pointed out that a range of further factors can intersect and interact to influence a multiracial individual’s experience. They include languages spoken, geographical and social milieu, and stereotyped beliefs about specific racial mixes.

Further, the same dominant beauty norms that are applied to the bodies of monoracial individuals are applied to multiracial people, to privilege thinness, youth, able-bodiedness, heterosexuality, and so forth [18]. Such emphasis on physical appearance may partially explain why multiracial women may be more affected by eating disorders. Ivezaj found that the incidence of binge eating disorder was higher among multiracial women compared to monoracial women [19].

On a more optimistic note, many researchers have noted multiracial individuals to have unique strengths stemming from their mixedness [8,20]. For example, multiracials have been found to show greater appreciation, tolerance and empathy in relation to cultural alterity [8,21]. Multiracials also defy and disrupt racial stereotypes-such as stereotyped performance expectations, thus challenging racist power structures [8]. As well, multiracials often have nuanced and fluid understandings of racialization that challenge racism and deepen understanding of the socially constructed aspects of race and racial identity. Social attitudes have changed over time and Canadian research also shows that not only are multiracial families on the rise, but also that individuals who are younger and with higher levels of education and income are more likely to marry outside of their racial group [14].

While a noticeable shift is occurring to recognize the strengths and resiliencies of this population, mainstream theories of healthy child development, identity development and personality are based on monoraciality as a normative reference point and may pathologize what is healthy and adaptive development for multiracials [21,22]. More research is required in this area both with regards to elucidating and understanding health inequities for multiracials, but also to understand the positives or areas of strength. This project aims to address the gap in the existing knowledge by understanding the experiences of multiracial community mental health clients with the aim of improving assessment, service provision and care planning. The further aim is to improve patient-centered approaches to care, and to learn how to enhance resiliencies amidst the unique stressors this population faces within the Canadian context.

Participants in this study and their families would have experienced the impacts of changing social policy such as the introduction of the Bill of Rights, the Charter of Rights and Freedoms and the Multiculturalism Act. Changes in immigration policy followed allowing for greater diversity in Canada. The socio-political climate in Canada needs to be taken into consideration when contextualizing the experiences of this population, including the Indian Act [23]. The Mental Health Commission of Canada has prioritized further service improvement, research and consideration of immigration, refugee and ethnoracial and racialized [IRER] groups as a special and underserved population [24]. According to their research, these groups face higher exposure to multiple social risk factors that impact mental health such as discrimination, migration, loss of social supports, power imbalances, mistrust of services, poverty, socioeconomic disadvantage and unemployment [24].

This study was an exploratory qualitative interview-based study informed by critical race theory (CRT). According to Creswell, "the use of CRT methodology means that the researcher foregrounds race and racism in all aspects of the research process; challenges the traditional research paradigms, texts and theories used to explain the experiences of people of color; and offers transformative solutions to racial, gender, and class subordination in our societal and institutional structures" [25]. Given the emergent nature of research with this population, the historical pathologization and criminalization of this group, and the saliency of race and racism in their experiences, a qualitative exploratory critical race framework was utilized throughout the research process. Informed by critical race theory, we sought to explore this under-recognized and emergent population and make an original contribution to inform best practices when working with multiracials in mental health.

Research Question

How has multiraciality affected the wellbeing of adult mental health clients in a Metro Vancouver city?

Methods

The study was given ethics approval by the Fraser Health Research Ethics Board. Participants were recruited from a community mental health centre serving adults with mental health and/or substance use disorders in Metro Vancouver. A purposeful sampling strategy was utilized to recruit participants. Palinkas et al. (2015) acknowledged that purposeful sampling constitutes a broad type of sampling strategy with many subtypes and that it “is widely used in qualitative research for the identification and selection of information-rich cases related to the phenomenon of interest” [26]. In this case, the phenomenon of interest was multiracialism in adult community mental health centre attendees. Case managers at the community mental health centre (i.e. psychiatric nurses, social workers, clinical counsellors) were made aware of the study in a series of staff meetings and were asked to assist in the study by identifying potential study participants. Suri stated that “purposeful sampling requires access to key informants in the field who can help identify information-rich cases”. In this case, the case managers played the role of key informants [27]. The case managers forwarded the names and contact details of potentially suitable clients to members of the research team who examined client records to ascertain if clients met the study’s inclusion criteria (see below). In this respect, the subcategory of purposeful sampling that was utilized was “criterion sampling” [26]. Those clients who met the inclusion criteria were invited to an informal meeting with the researchers to have further discussions about the study. As a result of that process, informed consent was obtained from 10 clients. All clients who were deemed to meet the inclusion criteria and who expressed an interest in participating were accepted into the study.

Participants were interviewed in one or two semi-structured recorded interviews. All interviews occurred between July 2015 and March 2016. All participants were Canadian-born and English speaking. The ages of participants ranged from 24 to 64 years old. There were 6 males, 3 females and 1 transgender female participant. Participants were a range of multiracial combinations. Participants had a range of diagnoses including Schizophrenia, Bipolar Disorder, Depression, Schizoaffective Disorder, Substance Use Disorder and Anorexia. Participants ranged in the length of their service at the mental health centre from between less than one year to more than 20 years.

Data was analyzed using thematic analysis [28]. Each interview was transcribed and coded by two members of the research team. Using the interview guide as an initial framework, the transcripts were coded for emergent themes. Themes were discussed at a collaborative data analysis session attended by the research team and then transcripts were read again for further analysis and discussion at a second collaborative data analysis session. These themes and sub-themes will be guided by a critical theory framework, considering the forms of oppression and barriers faced due to class, race, gender, religion, ability, appearance, language, and so forth.

Results

Strengths

A strong theme that resonated through the majority of the interviews was that of the strength of multiracial individuals. Many participants expressed that they felt more open towards other racial groups as a result of their experiences and deeply understood and were against racism. Several participants expressed that they felt empathy towards other marginalized groups due to their experiences with marginalization and racism. Patrick (Filipino/Malaysian/White) described that his own experiences being misunderstood have led him to be more open and non judgemental towards others “because we’ve had this experience, we’re not people who judge a book by its cover.” Merlyn (Japanese/White) stated he felt multiracials were more curious about others rather than just sticking to their own racial group. Gizmo (Filipino/White) described that being multiracial is like having a bigger family (ie belonging to multiple groups) and also felt multiracials were more openminded. Likewise, Patrick (stated he felt like he could pass as a member of multiple groups because of his appearance and that made him feel a wider sense of belonging. Sarah (Arab/White), despite being adopted and having many traumatic incidents of racism and exclusion, stated that all these experiences growing up multiracial allowed her to have a stronger sense of who she is. Likewise, Brittany (Native/White) also stated her experiences made her stronger. David felt enriched that he knew his Native language as well as English.

Experiences of racism and stereotyping

All of our participants described experiences of racism and stereotyping. At the age of 12, Ronald (Black/White) was called a “nigger” at school. In grade six, Brittany remembers being called racial slurs like “chuck wagon, wagon burner, and squaw.” She grew up half white and half native in a predominantly white neighbourhood and faced much racism at school. For Merlyn it was upon entering highschool that racial tensions and problems arose. Both Merlyn and Patrick described “racist jokes” that they were subjected to. Sarah found racism became more of an issue the older she got. Sarah noticed she was picked last at school and attributed this to her being “foreign looking”. Her sister, who was “Canadian looking” did not have the same experiences of exclusion and in fact was quite popular at school and ignored Sarah. Sarah later faced further discrimination from an employer as an adult. Merlyn too described a pattern of discriminatory behaviour towards him by an employer.

David (Native/White) felt he was treated unfairly at the liquor store, where he returned bottles, because he was stereotyped as a criminal and a "drunken Indian". Patrick faced less threatening stereotyping, that he must be a ‘good dancer’ since he looked Filipino. Merlyn faced steretyping that he must be good at math and science because he was Japanese. Merlyn stated that trying to meet these stereotypes has worn him down as he strived for the social acceptance that he thought would come if he could fit these expectations.

Another layer of racism experienced by participants was that at home or in the family.

David described how his mother rejected her own partnative identity, both by marrying a White man and by trying to pass as Filipino. He said his mother was “ashamed to be native”. She also adopted her husband’s European surname and David used it out of respect for her, but never officially changed his name. This did not stop David from developing a strong native identity himself.

Rainy (Japanese/White) felt like “the black sheep, cause I wasn’t blond and blue haired like all my cousins” and that his European grandparents “didn’t like me because I was part Japanese”. He also felt others were always watching him, to the point where even know he feels uncomfortable going out. Sarah experienced racism from her adopted parents, who vilified her biological parents. She was only told her about her European father and not her Arab mother. Given this denial of heritage and racism at school, it is not surprising that she never embraced her part-Arab ancestry and as an adult changed her name from Arabic to a English one. Ronald was also raised by White Canadian foster parents, but with an awareness that he had black ancestry through his biological father and in fact stated he identified as a ‘mulatto’ since birth.

There were some exceptions to experiences of racism within the family. Merlyn’s white Canadian mother sent him to Japanese school as a child, even after seperating from her Japanese partner. He was raised with art and toys from Japan casually around the house and came to embrace online Japanese gaming as his main community. Patrick also seemed to have a more supportive family environment and in his case, this seems to be possibly related to the fact that both his parents were both multiracial as well. Brittany remembered that her parents were supportive of her and her brother and so were her monoracial native cousins.

Community and belonging

Participants identified various places, environments and groups where they experienced community and belonging. Patrick found his belonging through a group of friends from different backgrounds that he met at school. Gizmo found his with his online gaming community, where he has a greater degree of control of how he is perceived by others. David found a sense of social connection through his church community. Rainy experienced community through his practice of martial arts. Where her family rejected her calling her illness satanic, Sarah found acceptance and inclusion at the local mental health clubhouse. Younger participants (Patrick, Gizmo, Merlyn, Rainy) seemed to be able to identify others in their schools who were multiracials and either had multiracial friends or had a diverse friend group as opposed to some of the older participants (Ronald, Sarah) who often were the only racialized student in the class.

Spirituality

David met his spiritual needs by attending church and reading the Bible. Rainy found Christianity meaningful as well to him; he attends church and uses a prayer rope when in distress. At the same time, he also practices meditation from his Japanese heritage, and sees no conflict in doing so. Sarah on the other hand had rejected the church that she was raised in by her foster parents and that viewed her illness as satanic. She identifies as a spirtualist. This is similar to the way that she forged her own transcedent racial identity as ‘Canadian’ rather than one from her ancestry or from her foster family. Likewise, Patrick identified as a spiritualist. Sarah and Patrick embraced transcendent identities for both their racial identities and spiritual identities. Merlyn found eastern philosophy and introspection a source of strength and meaning for him during his psychiatric admission. Bugsy (Native/White) expressed her belief in “Mother Earth” as a source of strength and meaning for her, and Gizmo embraced Buddhism.

Physicality and appearance

Many participants discussed the connection between physicality and racialization. Patrick, for example, felt that his physical appearance did not match his racial self-concept. He stated “I feel like I’m a white man in an Asian’s body” and went on to describe several incidents of others assuming that he was Filipino or Thai, based his on his physical appearance. As such, his mixedness was reduced to a singular (monoracial) identity in a way that rode roughshod over his own preferred identity. Patrick expressed his disgruntlement about this by saying “I wish they’d ask”. While this pattern of misidentification did not seem to have an enduring psychological impact, he did express frustration about having to give the “coles notes” version of his racial background for the sake of other people. He expressed his desire to not have to explain his racial background at all. Finally, he talked about how others read his body and assumed he did not speak English. That phenomenon arguably speaks to the lingering presence in our society of a colonial vision of Canadianness that privileges Canadians of white European ancestry as the true or real Canadians and which holds aboriginal and racialized peoples as foreign.

Rainy described how others exoticized him, often teasing him, or making comments along the lines that he was “an interesting mix”. He explained that his mixed race body was sometimes read as “feminine”. His physical appearance certainly does not conform to the dominant masculine physique and he was arguably subjected to a white heteronormative gaze that views Asian body-types such as his to be inferior. Merlyn made some reflective comments on how his view of gender, like his view of race, was more fluid that those around him and the fact that this often got him into trouble with his peers when he did not meet their gender expectations. Gizmo found that others did not accept his Filipino heritage because he ‘didn’t look Filipino’. He also struggled with the weight gain caused by his psychiatric medication. Merlyn thought being a larger man made more of an impression on others than his raciality. Kathy (Japanese/White) was very committed to maintaining a thin physique and spent hours at the gym in an effort to meet those exacting standards.

Identity and self-identification

Participants expressed a range of identifications discussed by Rockquemore (2003) from “singular” identies like White and Native to “border identities” such as multiracial/mixed race, Eurasian or half-Native to “protean identities” that shift in the situation to “transcendent” identities including human and Canadian [15]. Sarah’s identity shifted over time and as an adult she identified as “Canadian”. As an adult, she legally changed her name to an “English name”, affirming her chosen identity. Sarah also emphasizes the importance of staff recognizing and validating how she sees herself. Merlyn stated he was “Canadian-Japanese”. He also changed his name as an adult, although he changed his name to one that reflects his Japanese identity.

Gizmo identifies as ‘Half Filipino/Half Canadian’. Ronald on the other hand identified as “mulatto” from early childhood and maintains that identity today. Patrick and Kathy identify as ‘Eurasian’. Rainy identifies as “mixed race”. David often emphasized he saw himself as “Indian”, regardless of Native kids at school or the Canadian government recognizing his identity. Bugsy spoke about how recent changes in the law now allows her to claim Indian status through her mother, while for David he experienced the pain of having the government reject his claim for aboriginal identity because his mother and her mother married non-Aboriginal men. Participants had a clear view of how they self-identified and were able to express and discuss it in depth.

Good care and feedback

Participants identified good care as being respectful, professional, helpful, accessible and providing practical and effective support. Part of their expectations for health professionals were that they were sensitive to issues of diversity and respected the self-identification of clients. Merlyn suggested having a group for multiracial mental health clients at the centre as a away of bringing them together and sharing experiences. Several participants stated that having an accurate diagnosis was important for them as was receive education in relation to their diagnosis. Practical support was also considered to be important-be it on relation in to assistance in finding affordable housing or having access to further education. In addition, several participants emphasised the importance of having a case worker who can effectively and skillfully listen to the client’s concerns. All participants appreciated the oppourtunity to provide feedback through this study and although they noted they had not been asked for feedback in the past, were open and willing to provide feedback.

David stated that he was able to trust and feel comfort with his case manager on account of their shared identities as racialized men. David had not always been able to form such trusting relationhsips with care providers. As a younger man trying to negotiate the mental health system, he was often confined to the seclusion room and subjected to involunatry chemical restraint while in hospital. “They thought I was a violent person, but I’m only violent when I’m scared”. Like many Aboriginal young men, he found himself caught in a cycle of addiction, violence and police encounters for many years. Only after many years of such experiences did he have the good fortune of meeting a case manager whom he was able to form a trusting relationship with. A lack of judgement and patience were identified as essential characteristics in a case manager, by David. Other participants expressed a preference for working with racialized case managers and psychiatrists who were also racialized, even if they did not specifically discuss their experiences of racism with them. The assumption of a shared experience of racialization seems to have been the key factor here. This is in keeping with the recommendations of the Mental Health Commission of Canada that service providers should reflect the diversity of the clients they serve and to engage diverse communities in developing services [29].

Discussion

This study sought to explore the way in which multiraciality affected the wellbeing of adult mental health clients in a Metro Vancouver city. On the one hand, many of the participantsinitially at least- understated (and even denied) the possibility of the existence of a link between their multiraciality and negative psychological experiences. On the other hand, often after further discussion and exploration, there was a realization and acknowledgement that their racial status had occasioned discriminatory and in some cases, frankly abusive behaviours on the part of those whom they were in contact with. Experiences of racism were in fact reported across the lifespan and in a range of settings—incuding childhood and early adolesence, the family, school, at work, in public spaces and so forth. Often, the experiences of social rejection and invalidation proved to be significant factors that individuals were required to incorporate into their ongoing processes of defining themselves and negotiating their own senses of identity.

In addition to racism, many participants disclosed that they had experienced adverse events in their early childhood (such as parental divorce, incarceration of a parent, death of a parent, poverty, abuse, neglect, adoption). However, participants generally mimimized the possibility that such experiences might be etiologically relevant to the mental health problems with which they had suffered over the years. Research has also indicated that some psychosocial risk factors may have more of an impact on multiracials than their peers because of the importance of social validation for psychological wellbeing [30,31]. It also appears that although they were aware of their multiracial backgrounds, they have never been asked to consider how it has impacted their mental health, nor has it been considered in their mental health treatment. Mental health professionals might consider giving more thought to such issues in the future. There may also be unmet educational needs pertaining to multiraciality for mental health professionals.

Amidst a backdrop of racism and steretyping, participants found strength and deeper insight into human relations from their multiracial experiences. Participants developed a strong sense of identity, family, community and spirituality. Participants also described their keen empathy for other marginalized groups and awareness of racism and racial microaggressions. This study found that participants found personal strength and resilency from their adverse experiences. This deeper appreciation for human diversity and cross-cultural social skills has been discussed in multiracial research as a common strength from being multiracial [20]. Moreover, our study found participants wanted to talk about these issues and were very engaged in our interviews. Some participants carried their conversations beyond the interviews into their meetings with case managers, psychiatrists and other health care staff. One participant decided to apply for her Indian status following the interview.

Nadal et al. (2011) found five themes of microaggressions within multiracial families [12]. These included subtle insults, invalidations and emotional wounds include “isolation within the family, favoritism within the family, questioning of authenticity, denial of multiracial identity and experiences by monoracial families members and feelings about not learning about family heritage and culture”. Sarah’s adoptive parents seemed to endorse the ‘denial of multiracial identity’ by not allowing her to embrace her whole heritage and insisting that she follows the culture and religion of her adoptive parents. Likewise, David’s mother denied her own multiracial identity and tried to deny David his. David described that “my immediate family that I was raised with, they were prejudiced against me, because I look Native and acted Native, and they wanted to view themselves as White”. While rejected at home for being Native, David’s authenticity was questioned by Natives at school who didn’t accept him as Native because he had a white father, causing him to get into many school yard fights. Several participants felt isolated within their families or that other siblings were preferred. Although these family specific microaggressions could be experienced in monoracial families as well, these were layered onto external experiences of racism, exclusion, invalidation and discrimination for multiracial participants meaning their identities, self esteem and sense of belonging had to be constantly reassessed and negotiated. Acceptance from family, integrated identity and positive peer interactions seemed protective factors against these microaggressions.

In addition to the above microaggressions experienced more commonly within families, Nadal et al. (2011) identified other themes in microaggressions experienced of multiracials including ‘exclusion or isolation, exoticization and objectification, assumption of monoracial or mistaken identity, denial of multiracial reality and experiences, pathologizing of identity or experiences and microaggressions based on stereotypes [32]. The participants in this study identified specific microaggressions in their school lives ranging from peers at school assuming Patrick was a ‘good dancer’ because they thought he was Filipino (sterotyping), to Rainy being exoticized as "an interesting mix", to Gizmo beign told he ‘didn’t look Filipino’ (denial of identity), to Sarah being picked last to play on a team because she was racially different (exclusion). Ronald, Brittany, Merlyn and Patrick all spoke about experiencing racial jokes or taunts at school. Most participants identified that they became aware that they were racially different from their peers during elementary school and usually because of taunts from peers or noticing difference between themselves and their family members. This is particularly salient because racial identity emerges during the adolescence, a period when psychological wellbeing can hinge so much on being accepted into a peer group [33].

Patrick explained several situations where others made assumptions about his racial background rather than asking him (assumption of monoracial or mistaken identity). His experience also draws attention to the range of microaggressions multiracials face, for he also mentioned others assuming he didn’t speak English (assumption of foreignness) [34]. In other words, multiracials can face a wide range of microaggressions including those unique to multiracials and those experienced by other monoracial racialized groups. Moreoever, these microaggressions are further complicated by gendered norms, Rainy describing how others thought he was gay because they thought he was ‘feminine looking’ due to the white masculine gaze that others saw him through. Likewise another participant found that his weight was the main physical charateristic that drew the attention of others, masking his multiraciality, since his body size did not comply with dominant standards.

Over time, participants demonstrated a shift between seeking external validation of their identity to affirming their own identity without needing external validation. This shift from their self worth relying on external validation to internal control over their identity and self worth is a task counsellors can assist multiracials with exploring and actualizing [35]. This shift also demonstrates a very important change in the locus of control from others to the self. Walcott [36] discusses how early studies in psychology of Blacks focused on external dimensions of their experience, such as poverty, ignoring their inner experience of identity and culture. In this study, participants struggled with others making assumptions about them based on external characteristics while ultimately wanting others to recognize their inner experiences, whether that be seeing them as they see themselves (validating identity) or understanding their inner experiences (as a multiracial person). Thus the inner physic experience of multiraciality needs further attention, exploration and affirmation. This is another area for exploration then through psychotherapy to not only focus on family relations and experiences of racism but internal identity work and perceptions of control.

Practice implications

From this study and by reviewing the growing body of research on multiracial mental health, the following recommendations have emerged:

••Provide opportunities for multiracials to identify in a way in which they wish to do so. A wish for self-identification and self-determination was a major theme in this study and one way in which organizations can respond to this need is-in their intake forms-to make provisions for multiple group belonging or “other” categories of identification.

••In addition to supporting self-identification and increasing identity-validating experiences, better data collection is needed to identify and obtain quantitative as well as qualitative data pertaining to this population. Demographic data collection should be consistently collected and analysed across patient groups, but particularly in mental health given the additional stressors faced by racialized groups, including multiracials.

••Clinical interactions need to validate and honour the identity of multiracial individuals in a client-centred manner that avoids the imposition of externally generated identity categories. The often-fluid nature of multiracial identity needs to be considered. Clinicians can support clients will identity exploration, support their chosen identity and acknowledge and encourage open discussion and mutual learning about racism.

••Inviting feedback from multiracials about what constitutes good care for them can help create safer and more respectful clinical encounters. Culturally safe and competent care that supports self-identification, lived experience, patient centeredness, diversity, selfreflective practice, and is trauma informed is essential to effective and safe assessment, treatment and recovery. Understanding the unique oppression that a multiracial client may have experienced because of their background and contextualizing it with global and local understandings of discrimination is likely, in some cases, to be an important aspect of therapy.

••Other best practices may include training and tools to engage multiracial clients, hiring diverse staff, increasing outreach and community partnerships in mental health services, considering complimentary health treatments, increasing timely access to interpreter services and expanding language-specific services and educational materials [24,37,38]. Further staff education is needed to support staff in recognizing the impact of racism on mental health and wellbeing and other social risk factors experienced by multiracials, build resilience with clients, and ensure mental health services are safe and inclusive [39,40].

Conclusions

As far as we are aware, this was the first qualitative investigation of the experiences of adult multiracial clients in a community mental health centre. This research has provided a deeper understanding of the way in which multiraciality intersects not only with mental illness, but with embodiment, identity, community, and spirituality. While many of our clients described having had negative experiences, across the lifespan, and in different domains of life (home, work, in public spaces etc), this research highlighted the various strengths that emerged out of the multiracial experience. An example of that was individuals’ general sensitivity and attunement to issues of difference which often resulted in conscious commitments to upholding the values of tolerance and inclusivity. Several implications for mental health service delivery flowed from this research. These include the need for more awareness on the part of mental health clinicians about the experiences and needs of multiracial individuals. There are also implications for the way in which data pertaining to clients’ racial identity ought to be collected at an organizational level, in way that is perceived as culturally safe and in a way that is respectful of individual’s right to self-determination. The identity of multiracials rarely fits into neat categorical boxes, and the procedures for data collection followed by mental health organizations need to reflect and adapt to the fact.

Footnotes

In this study we have selected the term ‘multiracial’ to describe individuals whose parents are from different racial groups. Other terms used in the literature include biracial and mixed-race.

Aboriginal peoples of Canada are defined in the Indian Act and are counted by Statistics Canada in a separate category of Aboriginal Identity. Therefore, including the population of multiracial indigenous and Métis Canadians would significantly increase the size of the multiracial population in Canada.

Acknowledgement

This research was made possible through a Seed Grant from Fraser Health Authority in British Columbia, Canada. The seed grant number was 2015/035. We are especially grateful to the staff at the Fraser Health department of evaluation and research services for their invaluable guidance and support.

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