SAMHSA’S CHILDREN’S MENTAL HEALTH INITIATIVE

1. SAMHSA’SCHILDREN’S MENTAL HEALTH INITIATIVE

2. One Community’s Experience Implementing the California Brief Multicultural Competence ScaleMulticultural Training with System, Community, and Family Partners Building Culturally Competent and Diverse Organizations and Systems of Care Conference, 9/26/2013, Lansing, MI Presenters: Saginaw Max System of Care Lula Haynes, Parent Support Partner (ACMH) Yalonda Freeman, Secretary of the Empowered to Reach and Teach Families Team Wardene Talley, Director Dalia Smith, Cultural and Linguistics Competency Coordinator

3. Today’s Objectives • Describe 4 indicators within a system that would identify a need for Multicultural Training. • Identify 8 key partners to assist with developing a community wide cultural competence training plan. • List 6 biases that impact clinical practice.

4. Acknowledgements Richard Dana, Portland State University Glen Gamst, University of La Verne Aghop Der-Karabetian, University of La Verne With Contributions From: Leticia Arellano-Morales, University of La Verne Marya Endriga, California State University, Sacramento Robbin Huff-Musgrove, Patton State Hospital Gloria Morrow, Private Practice With Generous Support From: California Department of Mental Health Office of Multicultural Services Eli Lilly Foundation California Mental Health Directors Association California Institute of Mental Health University of La Verne, La Verne, CA

5. Conocimiento Activity(knowledge through sharing) • Select a partner and ask the following questions over the next five minutes. Be prepared to introduce your partner based on the information shared after seeking your partners permission: • What is you name? Is there a story to your name? Are you named after someone? • Where do you work and how does the work you do fit with your personal philosophy of life? • Name one cultural fact about yourself that we would not be able to tell by looking at you.

6. The Danger of the Single Story Chimamanda Ngozi Adichie

7. Urgency • Community Demographics: • Saginaw County pop. 198,353 • Saginaw City pop. 50,790 • 2nd highest rate of poverty in MI: • Saginaw County 18.6% • Saginaw City 36.9% • 3rd Most Violent City in Nation • 2013 FBI ranking (per capita) • 2013 Statistics: • Saginaw County – 25 confirmed homicides as of 9/13/13 • Saginaw City - 23 • Milton Hall • Saginaw is a traumatized community! • Saginaw County: • Hispanic/Latino/a 19.4% • Black/African American 7.9% • Saginaw City: • Hispanic/Latino/a 46.1% • Black/African American 14.3% (U.S. Census QuickFacts, 2010 and 2012)

8. Milton Hall Another Story

9. Collaborative Decision Making Process • Convened Saginaw Max Evaluation Advisory Team (January 2011) • Made up of multiple system, community and family partners. • Completed a Strengths and Needs Assessment (Spring 2011) • Identified a need for multicultural training for system partners. • Created a Logic Model (June 2011) • Approved by the Coordinating Council (Saginaw Max’s decision making body). • Took advantage of a training opportunity offered by the Technical Assistance Partnership (August 2011) • CBMCS Multicultural Training • Began work on Saginaw Max Strategic Plan (September 2011) • The strategic plan outlines the action steps to achieve Saginaw Max objectives including cultural and linguistic competency.

10. Data Informed Saginaw County Youth Data Why We Need a System of Care • Between May 2004 and January 2013, 5,739 MAYSI-2 mental health screens were completed by juveniles under the jurisdiction of the Saginaw County Circuit Court - Family Division.  In 1,974 of these screens (34.4%), youth admitted that they have personally witnessed someone get severely injured or killed. • Juveniles complete a MAYSI-2 screen every time they are adjudicated or every three months during a lengthy sentence.  As of January 2013, MAYSI-2 screens were completed by 3,004 individual youth of which 40.3% (1,212) admitted at least once that they personally witnessed someone get severely injured or killed.  • Of the 5,739 MAYSI-2 screens completed by juveniles under the jurisdiction of the Saginaw County Circuit Court - Family Division between May 2004 and January 2013, 4,213 screens (73.4%) indicated that the youth appears to have a mental health concern in one or more areas. • In 2008, Saginaw County Community Mental Health Authority and the Saginaw Department of Human Services collaborated to determine the extent of mental health needs of youth in foster care. Based on assessments conducted with a representative sample of all Saginaw County youth in foster care at the time, results revealed that as many as sixty-nine percent (68.75%) of children in foster care in Saginaw County had moderate to critical mental health needs. • Between January 2004 and June 2009, 41% of youth who were originally involved with the court due to neglect and abuse were eventually charged with crimes

11. Saginaw County System of Care Partnerships • Saginaw Max has provided CBMCS Multicultural Training to 77 individuals in Saginaw County (2013) • Saginaw Public Health Department (April 2013) • Saginaw Department of Human Services (June 2013) • Disproportionate Minority Contact Initiative (September 2013) • Disproportionate Minority Contact (DMC) Initiative • There is disproportionality in our juvenile court and child welfare systems. • Gearing up to implement a countywide multicultural training program. • Health and Social Equity Advisory Group sponsored by Project LAUNCH • Ties into our PHD Community Health Improvement Plan (CHIP). • Priority 1 of 3 - Infant Mortality: • Saginaw County (3.7) • Saginaw City (4.4) • Saginaw Max System of Care (SAMHSA funded site) • Cultural and Linguistic Competency (CLC) Team • Alignment Saginaw

12. California Brief Multicultural Competence Scale (CBMCS) Development • The CBMCS was developed as a response to the Surgeon General’s Report and Supplement Report on mental health. • Goal: Develop a Multicultural Competence Scale easily administered and scored. • 1999 Scale Developed • 2000 lengthy Questionnaire 5-Scale (137 questions) • 2000-01 #1,244 CA practitioners participated • 2001 Client/Family members reviewed • 2001-02 Training manual – Richard Dana, PhD • 2002-03 From manual to training.

13. Development of CBMCS Training • Summer 2004, 40 MH cultural competence experts participate in review of CBMCS Training, representing 14 counties and state DMH • CBMCS 4 Modules were revised • Summer 2005/06 15 experts revised the CBMCS training from MH provider input • Fall 2006 Pilot of CBMCS begins • The CBMCS represents a true partnership between State and Local Mental Health and University evidence based research and development.

14. Selected CBMCS Pilot Sites • 5 Counties selected from original 14 counties that participated in early review • Kern County – training completed Oct. 2006 • San Bernardino • Sacramento • Santa Clara • San Francisco • All pilots to be completed by February 2007

15. CBMCS Training for Trainers and Staff Training Nationwide • Between 2006 – present: • Yreka County, CA • Imperial County, CA • Ventura County, CA • Forth Worth, Texas • Alameda County, CA • Solano County, CA (CIMH) • Pittsburg, PA • Hartford, CT • Ontario, CA (hosted by Dr. Morrow where trainers came from all across the United States) • Plainview, Texas • Merced County, CA (CIMH) • Stanislaus County, CA (CIMH) • Commissioned by Ken Martinez to provide CBMCS training in Denver, CO and Atlanta, GA • Egyptian Health Department, IL

16. Reviewed Existing Literature • The development group identified 5 self-report cultural competence instruments: • CCCI-R La Fromboise, et al. • MAKSS D’Andrea, et al. • MCAS-B Ponterotto, et al. • MCCTS Holcomb-McCoy • MCI Sodowsky, et al. • Most of these instruments were 45-60 items long and developed on university student populations.

17. The California Brief Multicultural Competence Scale and Multicultural Training Program • This scale consists of 4 subscales: • Multicultural Knowledge • Awareness of Cultural Barriers • Sensitivity and Responsiveness to Consumers • Sociocultural Diversities • An 8-hour training program is available for each subscale. • 32 multicultural training CEUs offered • The CBMCS is a 21-item self-assessment of cultural competence.

18. Utility • The CBMCS can be used by an agency to identify the training needs of the agency staff. • The unique aspect of this scale is that it has its own Training Program that “flows” from the scale.

19. Application • Agencies can use the CBMCS scale to target which staff should receive a particular module. OR • Agencies could run staff through all 4 modules. • The CBMCS scale could be used as a pre-post measure of training effectiveness, along with client outcome or satisfaction measures.

20. Current Status • The CBMCS instrument is being used across the country in over 20 sites. • The CBMCS Training Program and the Train the Trainer Program have gone national.

21. Setting the Tone • It’s very important that participants commit to the entire length of the training. • This is an intensive multicultural training. • Consistency is needed to create a “safe” learning environment. • Ground Rules and a “Parking Lot” are important tools. • Review of the Transitional Stages of Change is important. • Denial (of differences), defense (against differences), minimization (bury differences under cultural similarities), acceptance (of cultural differences), adaptation (of behavior and thinking to that difference)

22. U.S. Surgeon General’s Report • 1999 U.S. Surgeon General developed a report on mental health, Mental Health: A Report of the Surgeon General. • 2001 U.S. Surgeon General created a supplemental report to the one on mental health focusing on the four major minority groups, A Supplement to Mental Health: A Report of the Surgeon General. • African American • Latino American • Asian American • Native American Indian

23. Challenges to the Mental Health System: U.S. Surgeon General’s Report • U.S. mental health system maybe ill prepared to meet the mental health needs of racial/ethnic groups due to deficiencies in level of cultural competence among service providers of all types (e.g. psychiatrists, therapists, case managers). • Unique cultural differences exist among racial/ethnic groups with regard to coping styles, utilization of services, help-seeking attitudes and behaviors, and the use of family and community as resources. (U.S. Department of Health and Human Services, 2001)

24. Another Story

25. Mental Health Disparities:African Americans • May be at higher risk of mental disorders than the White population due to socioeconomic differences (Reiger, Narrow, Rae, Manderscheid, Locke & Goodwin, 1993a). • Tend to be underrepresented in outpatient treatment, yet overrepresented (by twice as many) in inpatient treatment (Snowden & Cheung, 1990; Snowden, 2001). • More likely to use emergency room for mental health problems than the White population (Snowden, 2001). • Higher rates of misdiagnosis as compared to the White population and consequently, mistakes lead to the use of inappropriate medications. • Disproportionately represented in homeless, incarcerated, and child welfare populations, and as victims of trauma – all risk factors for mental illness. (Surgeon General, 2001)

26. Mental Health Disparities:American Indian/Alaskan Native • Few epidemiological surveys of mental health and mental disorders. • Depression is a significant problem for many American Indians/Alaskan Natives. • Higher risk of alcohol abuse and dependence. • High rates of suicide (50% higher than national rate) • U.S. veterans have higher prevalence rates of PTSD than the White population. (Surgeon General, 2001)

27. Mental Health Disparities:Asian Americans/Pacific Islanders • Model Minority Myth and other subgroup stereotypes. • Under utilization due to stigma and shame. • Delay seeking services until problems become very serious. • Access barriers due to lack of language proficiency of service providers. (Surgeon General, 2001)

28. Mental Health Disparities:Hispanic/Latino/a Americans • Prevalence rates of mental disorders in Mexican-born Mexican Americans similar to general population, however, • Prevalence rates for depression and phobias are higher in U.S. born Mexican Americans relative to European Americans. • Limited data is available for some Latino/a groups (e.g. Cuban, Puerto Rican, Guatemalan, etc.). • Latino/a immigrants have very limited access to mental health services. • Latino/a youth are at high risk for poor mental health outcomes. • Historical and sociocultural factors suggest Latinos/as are in great need of mental health services. • As many as 40% of Hispanic Americans report limited English language proficiency. (Surgeon General, 2001)

29. Mental Health Disparities:U.S. Surgeon General Report • Minority communities have disproportionately high burden of disability from untreated or inadequately treated mental health problems. • Additionally, we must also understand that other groups have experienced oppression throughout the United States and the world. Some of these groups are immigrants from Europe, people who are Jewish, people who are Middle Eastern, women, the LGBTQ community, the disabled, and those who live in poverty. • CULTURE COUNTS! (Surgeon General, 2001)

30. Training Goals • To be introduced to a historical overview of the CBMCS; • To gain a better understanding of what cultural competence/responsiveness means, and its relevance; • A review of the mental health disparities and historical oppression among children, youth, and parents who are members of the four major ethnic/racial groups; • To become aware of empirical knowledge concerning the mental health status of ethnic/racial groups;

31. Training Goals (cont.) • To recognize deficiencies in related research. • To critique traditional theories and consider new ones. • To examine how cultural responsiveness is reflected in our system of care; • To explore the cultural responsiveness needs system-wide; • Improve sensitivity to experiences and worldview of consumers. • Improve sensitivity and responsiveness to the effects of racism, oppression, and discrimination on consumers mental health services. • Improve sensitivity to the impact of provider and consumer social values and communication styles. • Improve sensitivity to the importance of consumer advocacy. • Service delivery implications (ex. bad practices = malpractice).

32. Another Story

33. Training Goals (cont.) • To discuss the barriers to cultural responsiveness; • Self-awareness of personal values, beliefs, and ethnic/racial/cultural background. • Self-awareness of privilege, bias, and stereotypes. • To discuss the benefits of increasing cultural responsiveness using the CBMCS curriculum. • To extend the parameters of diversity beyond the limits of ethnic/racial populations. • To explore the interactions of multiple human identity components

34. Another Story

35. Creates change in the heart (not just the “head”).

36. Lessons Learned • 8 hours per day may be too much. • The best format for training may be 4 consecutive days or 2-2 consecutive days over 2 weeks. • Participants may be better able to engage with training content when the audience is a mixture of system, community, family and youth partners. • Participants are better able to integrate culturally responsive behavior when they do not see it as something that has to be added onto an already heavy workload. • Some materials had to be modified and/or deleted. • The addition of more experiential opportunities with more process time given is necessary. • Trainers must be sufficiently skilled in facilitating this type of training. • Individuals inevitable find the training experience as emotionally charged. However, many of the same individuals say the curriculum has changed their lives in positive ways, both personally and professionally.

37. Preparation for Countywide Multicultural Training: • It takes patience to build urgency and gain buy in at all levels. • The community needs to have dialogue around 3 questions: • Is cultural and linguistic competency important? • If it is important, are we a culturally and linguistically competent community? • If we aren’t there yet, what do we need to do to be a culturally and linguistically competent community? • The community needs to be engaged in a data informed, collaborative, decision making process. • Families, youth, community and system partners need to agree on an objective and strategy that everyone can get behind. • Key leaders need to be engaged (champions).

38. Planning for Countywide Multicultural Training: • Secure funding resources. • Blended and braided funding. • Build into Strategic Plans. • Leverage Federal and/or State monies dedicated to CLC issues (DMC, violence, trauma, health disparities, etc.). • Use an application (and interview) process to identify potential trainers. • Publically acknowledge those who have been chosen to be trainers. • Collect and use local vignettes, data, and current events to make the training meaningful to participants. • Trainings may benefit from being off site. • Engage faith based community (needs a different approach).

39. Implementing Countywide Multicultural Training: • Commitment from system leadership to address barriers. • Ex. Encourage and allow staff to attend a 4-day (32 hour) training. • Trainers must be sufficiently skilled in facilitating this type of training. • Quality coaching, consultation, and mentoring is essential. • Measure, track, and monitor outcomes. • Think ahead for sustainability. • Build a core group of trainers from multiple disciplines (teams of 2). • Integrate into core training requirements.

40. Coaching, Consulting and Mentoring Dr. Gloria Morrow is one of the nation's leading clinical psychologists, who devoted her early career to teaching students in undergraduate and graduate psychology programs. As an academician, clinician and author, her teaching, counseling and books have helped thousands of people find true inner healing. As an academician and researcher, Dr. Gloria has presented the results of her research at professional conferences all over the world, including the University of Cape Town, in Cape Town, South Africa. As a top-rated professional with profound insight in her trade, she has been featured in a host of newspapers, (such as the award-winning Inland Valley News, an African American weekly). In addition to her published work in scholarly journals and books, she has been cited in critically acclaimed national publications such as “Psychology Today,” “Jet,” “Heart and Soul,” “Essence,” “Woman’s Day,” and “Black Enterprise.” Dr. Gloria is a Master Trainer for the CBMCS (California Brief Multicultural Competency Scale) Training Program, and she helped to develop the training curriculum. This program focuses on the four major ethnic groups: African American, Asian/Pacific Islanders, Hispanic/Latino/Mexican American, and American Indian/Native American. However, includes other diverse communities, such as the Muslim and Middle Eastern cultures in her training. In addition, she has facilitated several workshops and seminars focusing on cultural competency issues, such as the role of Spirituality in recovery. She was commissioned to develop a Spirituality Toolkit for the California Institute of Mental Health. Dr. Gloria holds an earned PhD in Clinical Psychology from Fielding Graduate University, Santa Barbara, CA; a Master of Science degree in Marriage and Family Therapy from Azusa Pacific University, Azusa, CA; and a Bachelors of Science degree in Psychology from the University of La Verne, La Verne, CA.

41. Questions

42. In Closing

43. Contact Information Yalonda Freeman Secretary (2013-2014) Saginaw Max Empowered to Reach and Teach Families (ERTFT) Team yalondafreeatlast@gmail.com Lula Haynes Parent Support Partner Association for Children’s Mental Health (ACMH) lhaynes@sccmha.org 989-797-3409

44. Contact Information • Wardene Talley Project Director 989-797-3562 wtalley@sccmha.org • Dalia Smith Cultural and Linguistics Competency Coordinator 989-498-2270 dsmith@sccmha.org • Willie Hillman Youth Involvement Coordinator 989-272-7232 whillman@sccmha.org • Keva Clark Lead Family Representative 989-797-3534 kclark@sccmha.org • Kelley Blanck Technical Assistance Coordinator 989-797-3556 kblanck@sccmha.org • Melissa Lee Social Marketing Coordinator 989-272-7209 mlee@sccmha.org • Ashley Wilcox Administrative Coordinator 989-272-7229 awilcox@sccmha.org