Enhancing Cross-Cultural Mental Health Care: Insights for Clinicians

1. Reinventing Ourselves as Mental Health Clinicians When Working with Refugee and Immigrant Populations October 31, 2008 MIAB Conference The $ and Sense of Culturally Effective Care:  Access, Communication, and Commitment Zarita Araújo-Lane, LICSW Cross Cultural Communication Systems, Inc. Tel: (781) 729-3736 ext.105 Email: zaraujo_lane@cccsorg.com

2. What does this sign tells you?

3. PERCEPTIONS

4. Perception Towards Your Assistance

5. Goals • To understand your clinical construct • To understand how to work with  interpreters • To understand how to engage and treat immigrant and refugee populations

6. Goal # 1 To understand your clinical construct

7. Providers vs. Helpersadapted from Randall-David (1989) • Counselors • Psychiatrists • Psychologists • Social Workers • Ministers • Curanderos • Ministers • Root Workers • Vodoo Priests • Medicine Men • Herbalists • Family / Friends • Espiritistas

8. “…mentally ill patients have the right not to be abused but also they have the right to the best available mental health care”(Adopted by the General Assembly of the United Nations, 1991). Copied: Ethics Culture and Psychiatry by Okasha et al, 2000

9. Programs need to not only treat and rehabilitate but also promote mental health A need to develop a collaborative approach with other professional community members and families A need for strategy ‘s temporal validity. (constant evaluation of short and long term goals) Copied: Ethics Culture and Psychiatry by Okasha et al, 2000 Declaration of Madrid,1960-1970Mental Health Programs

10. Guilt ‘when individuals engage in wrongful behaviors and this is a type of an individual experience’ Shame ‘when individuals engage in wrongful behaviors and this is a type of collective (family, friends, community) experience’ Autonomy vs. CollectivismAdapted from Derald Wing Sue and David Sue (2003)

11. How is the community going to perceive the fact that I need Mental Health Services? How is my family going to perceive the fact that I need Mental Health Services? STIGMA a FORM of SHAME

12. Stigma/Shame “I Must Have Done Something Wrong…” “I Should Pay for My Sins…” “There is Nothing You or I Can DO…”

13. And now EVERYONE in my family and community… is going to know what I have done!

14. These are the words of many patients who were referred to out-patient mental health services for evaluations and treatment.

15. In Summary: • Patient and or family who may feel shame or guilt and do not seek help • Mental Illness can be perceived as a punishment or bad karma • Patient sees illness in a fatalistic way Adapted: Clinical Manual for Cultural Psychiatry by Dr. Lim, 2006

16. Precipitant Factors for Referrals • Chronic illnesses, yearly check-ups • Children with academic problems • Children with behavioral problems • Couples struggling with staying together • Alcoholism in the family • Mental illness • Inability to keep up with work demands

17. Referral Sources • Community Organizations with key community advocates that speak the patient’s language • Community Health Centers and Pediatricians or Primary Care Physicians • Schools with Special Education Departments • Court Systems and Probation Officers or CAB • Emergency Rooms • Other Community Members

18. Building Trust

19. Fundamentals of trust • Competence • Sincerity • Involvement Copied from Business Design Associates, Inc. 2002

20. We all have a need to feel and express: Respect Respect is the acknowledgement of a person’s roots through a behavior • Honor • is a sense of worth or dignity that is defined by actions prescribed in a person’s traditions, rituals or history. Generosity A willingness to do something out of the ordinary that creates the sense of common ground with another. Trust Trust is a feeling or assessment that is evoked in a person involved in an interpersonal interaction. person’s roots

21. Respect Means Honoring Boundaries • “Respect also means honoring people’s boundaries to the point of protecting them.” (Copied from Dialogue and the Art of Thinking Together by William Isaacs,1999, Random House Publishing)

22. Respect Means Honoring Boundaries “If you respect someone, you do not intrude.” (Copied from Dialogue and the Art of Thinking Together by William Isaacs,1999, Random House Publishing)

23. Respect Means Honoring Boundaries • “ At the same time, if you respect someone, you do not withhold yourself or distance yourself from them.” (Copied from Dialogue and the Art of Thinking Together by William Isaacs,1999, Random House Publishing)

24. Eliciting the patient’s model of illness as per Dr. KleinmanDialogue with the patient • What do you think caused your problem? • Why do you think it started when it did? • How bad (severe) do you think your illness is? • What do you think your sickness does to you? • Do you think it will last a long time, or will it be better soon in your opinion?

25. Dr. Kleinman’s Model • What kind of treatment would you like to have? • What are the most important results you hope to get from treatment? • What are the chief problems your illness has caused you? • What do you fear most about your sickness?

26. Pay attention to the story! • Use same words as the patient, at first, as a way of showing that you are listening!

27. Cultural Formulation cultural identity of the individual and cultural explanations of the illness

28. What is culture? According to Fergurson ( 1991) Culture is interactional and dynamic. (just one aspect of an individual’s identity; along with others aspects such as gender, age, and class)

29. What is culture? According to Bonder et all (2002) Culture is learned. We are shaped by the belief systems around us. One is not born with knowledge of a culture

30. What is culture? Huges (1976) defined culture as a “learned configuration of images and other symbolic elements(such as language) widely shared among members of a given society or social group which, for individuals, functions as an orientational framework for behavior.”

31. Culture • Written Rules- laws, codes, standards • Unwritten rules- mores • World View- a set of assumptions about a person’s environment

32. What is culture competency? According to CLAS Standards Being able to recognize and respond to health–related beliefs and cultural values, disease incidence and prevalence and treatment efficiency

33. What is culture competency? • On-going assessment of how one’s own values interact with the other person’s values. • The ability to live with the fact that there are many sides (truths) to a story.

34. What is culture competency? • Paying attention to the individual. • Connecting around the other person’s thinking by echoing it.

35. Transference and Countertransference Issues Understanding your and the patient’s worldview

36. Overcompliance Denial of ethnocultural factors Mistrust Hostility Ambivalence Omniscient-omnipotent therapist The traitor Autoracism Ambivalence TransferenceInterethnic / Intraethnic effects Adapted: Clinical Manual for Cultural Psychiatry by Dr. Lim, 2006

37. Denial of Etnhocultural factor Clinical Anthropologist syndrome Guilt or pity Aggression Ambivalence Overidentification Distancing Cultural Myopia Ambivalence Anger Survivor’s guilt CountertransferenceInterethnic / Intraethnic effects Adapted: Clinical Manual for Cultural Psychiatry by Dr. Lim, 2006

38. Four Layers of Diversity: Organizational Dimensions External Dimensions Internal Dimensions Personality Race Age Gender Ethnicity Sexual Orientation Physical ability Geographic Location Income Personal Habits Recreational Habits Religion Educational Background Work Experience Appearance Parental status Marital status Functional Level/Classifications Work Content Field Division/Department/Unit/Group Seniority Work location Union Affiliation Management Status Copied from: Gardenswartz, Lee and Rowe, Anita. Managing Diversity. MC Graw-Hill. 1998

39. Three Culture Patterns Copied from: Carr-Ruffino, Norma. Managing Diversity. Thomson Publishing's, 1995

40. Four Character Values by CCCS • Honor • Respect • Generosity • Trust Developed by CCCS, Inc. 1996

41. Goal # 2 To understand how to work with  interpreters

42. Accuracy in Mental Health interpretation The understanding and conversion of meaning From source to target language. The understanding of purpose for session The understanding of silences

43. Interpreter Roles • Conduit • Clarifier • Culture broker • Patient advocate Bridging the Gap Manual

44. The Triadic Relationship

45. Pre-session • (CIFE) • C onfidential • I first person • F low • E verything will be interpreted

46. Session • Interpreter • Manages the flow • Has good listening skills • Is able to project voice • Is able to check-in when in doubt (clarification)

47. Post- session • Makes sure that patient understood • Interpreter • Follows patient to the other visits • if approved by institution • Assists scheduling future • Appointments • Requests consult with provider if necessary

48. Accuracy No______ • omissions • additions • false fluencies • distortions

49. Goal # 3 To understand how to engage and treat immigrant and refugee populations

50. Initiating Conversation Towards Trust • Work with patient’s conceptual system regarding the seeking of mental health care services • Negotiate and Compromise (location, language, gender, confidentiality, interaction in community) • Involve key players (community, religious, family, work, etc.)