Mental Health Issues in Work with Immigrants and Refugees

1. Mental Health Issues in Work with Immigrants and Refugees Georgi Kroupin, MA,LP Center for International Health, St. Paul, MN

2. New Americans: Understanding & Working With Their Mental Health Needs New Americans: Ordinary people under extraordinary stress

3. New Americans • Pull immigration • Push immigration • We mostly deal with the Push immigrants/refugees who experience stress on multiple levels

4. People balancing loss and gain:living through Opportunities • For many – basic safety and security • For some (seniors, handicapped people, women) more possibilities for independence and self-sufficiency • Freedom or communication/information

5. People balancing loss and gain:living through Internal Losses (individual) • Loss of Ease of Communication • Loss of Independence and Self-Sufficiency • Loss of Security and Stability

6. People balancing loss and gain:living through Environmental losses (individual) Negative Response: • Feeling that life was useless • Difficulty finding your niche in the future • Acculturation difficulties • Hopelessness about the future

7. People balancing loss and gain:living through Opportunities • Perspective of gain of material possessions • Opportunities for learning • Opportunities for cultural development for those who were denied their culture • Access to social services for those who need assistance

8. People balancing loss and gain:living through Environmental losses (individual) • Loss of Material Possessions • Loss of Value of Education and Professional Experience • Loss of Roots and Connection to Cultural and Social Traditions • Loss of Connection to Family and Friends

9. People balancing loss and gain:living through Opportunities • For those who were denied them, gain of basic civil rights • For those who were denied it - may be an opportunity to find their cultural identity

10. People balancing loss and gain:living through Internal Losses (individual) Negative Response: • Feeling powerless, unable to control or even predict future • Lack of trust in the system • Isolation and Confusion • Overuse and Pressure

11. People balancing loss and gain:living through Internal Losses (individual) • Loss of Status • Loss of Self-Esteem and Personal Identity

12. People balancing loss and gain:living through Internal Losses(individual) Negative Response: • Drinking/Drugs/Gambling • Family abuse • Adultery • Mental Health problems • Physical illness

13. Irreversible loss and hope for the future • Many refugees have experienced irreversible loss • Many also show incredible resilience • They may be able to learn how to live with loss and still have hope • We need to learn how to tolerate ambiguity and deal with balancing both parts at once

14. People balancing loss and gain:living through Refugee family with a sick child:Angry father Mother Father Social worker MD Pediatrician Daughter 16 Occupational therapist Daughter 2.5 Son 6 Son 12 Nurse Physical therapist Interpreter

15. From DSM-I to DSM-IIIR: From symbols to signs • In Biomedicine diseases are largely biological in nature • Disease entities are empirical and universal • They are “discovered” and then described in increasingly full terms

16. From DSM-I to DSM-IIIR: From symbols to signs Pre-DSM period • 1840 – “idiocy and insanity” • 1880 – “mania, melancholia, monomania, paresis, dementia, dipsomania and epilepsy” • 1917 – American Medico-psychological Association: uniform statistics for hospitals. Revised in 1934 • Revised by the Veterans Administration and the Navy during and after WWII (W. Menninger)

17. From DSM-I to DSM-IIIR: From symbols to signs • Mental Hospital Service of the American Psychiatric Association published DSM-I • The hallmark of DSM-I is the idea of “reaction” • Symptoms as symbolic statements of underlying problems

18. From DSM-I to DSM-IIIR: From symbols to signs • 1968 – DSM-II • Stepped away from the idea of psychobiosocial conceptions of mental disorders and dropped the label of “reactive” • Retained the idea that mental illnesses are symbolic expressions of hidden psychological realities

19. From DSM-I to DSM-IIIR: From symbols to signs • DSM-III and IIIR: from symbols to symptoms • Atheoretical and descriptive • Term “neurosis” dropped as concealing ethiological explanations • Intentional move away from psychological understanding of mental disorders • A clear step toward the exclusive use of biological ethiological models • Biological model was believed to be more scientific and more mainstream in terms of medicine

20. From DSM-I to DSM-IIIR: From symbols to signs • DSM-IIIR: identification of symptoms is transformed an interpretation of symbols of distress into a reading of signs of disease • Away from psychosociocultural context • Biological discourse replaces an existential, phenomenological one • The afflicted are represented in a purely biological discourse: Schizophrenic replaced by a person with schizophrenia

21. From DSM-I to DSM-IIIR: From symbols to signs • Classifications of mental disorders (DSM-IIIR, IV) reflect a momentum in a cultural historic process • Psychiatric classifications may be seen as historical and semantic processes, not “things”

22. From DSM-I to DSM-IIIRGaines (1992) • In Northern Germanic (Protestant) tradition self is “egocentric” • It is the locus of action, thought and emotion • Self is distinct, autonomous and capable of control and it is a source and center of motivation • Social and natural worlds are independent of self and ideally are subject to the actions of self • Individual is believed of literally making him or herself • Individuation and personal development/growth are central popular and professional issues

23. From DSM-I to DSM-IIIRGaines (1992) • Centrality of notion of “self-control” in the Germanic tradition (and DSM III+) • Ideal self is the one of “self-mastery” • “Out-of-control” states are seen as “pathological” • Treatment is designed to assist regaining the ideal of control

24. From DSM-I to DSM-IIIRGaines (1992) • The notion of self as responsible for (self) control is a central concept guiding clinical practice • Clinicians interpret patients without this (unconscious) motivation as “not trying”, “unconcerned about their condition”, “not taking care of themselves”, “not involved in their own treatment” (lack of “agency”) • It may result in problematic patient/provider interactions

25. From DSM-I to DSM-IIIRGaines (1992) • Mediterranean self is “sociocentric” • Self concept incorporates other persons • Individual character is partially determined by “related others” (family, “people”) • Self is dependent on the environment and is not completely under self’s control • Self is a dependent social construct, not an independent psychological one

26. New Americans:Building a working relationship • Establish rapport • Acknowledge stress and loss • Access strengths and opportunities • Encourage their initiative

27. Refugee Families balancing challenges and opportunities: adaptation Refugee family with a deaf second wife First wife/mother 55 Husband 65 IP: Second wife 40 MD Son 26 Son 22 Daughter 20 Son 18 . Daughter 16 DHH Advocate Child protection Police Family Therapist

28. Cultural issues in providing care • There are barriers in our work that are related to cultural differences and there are other obstacles that may look as such • We need to differentiate between the two

29. Cultural issues in providing care • We often need to accept our cultural incompetence • We are more similar than different • Being different can be an advantage • We can use both similarities and differences to learn, understand, build trust, and help

30. Cultural issues in providing care Refugee family with a sick child:An accident Mother Father Psychologist Midwife Son 7m.o. Nurse Child Protection Physical therapist Interpreter

31. Balancing incompetence and skill: collaboration Aspects which are frequently cultural • Explanatory models of problems • Manifestations of mental health problems • Communicating mental health problems • Understanding/accessing social and MH services • Communication and decision making patterns among family-client/patient-helping professional • Cultural acceptability of solutions

32. Balancing incompetence and skill: collaboration Assessment: • Most of existing instruments are not translated • Issues with construct validity: many Western concepts do not exist in other cultures • Issues with other validity: mental health problems are manifested differently in different cultures • There are major practical limitations: literacy, educational level, etc.

33. Balancing incompetence and skill: collaboration Barriers, which masquerade as cultural • Communication problems on part of helping professionals • Language barrier, poor use of interpreters • Frank disagreement of clients and their families with professional recommendations  • Common histories of trauma, loss, political or war violence

34. Language, Culture and Psychopathology Westermeyer & Janca (1997) Language and Cultural issues in MH • Denotation • Connotation • Equivalence in translated materials • Specificity of terms • Reporting threshold in relation to symptom severity

35. Language, Culture and Psychopathology Westermeyer & Janca (1997) Translation of mental health assessment instruments • Translation by a team of bilingual persons • Back translation by one or more persons not familiar with the original version • Analysis of the three versions • A pilot study in the target population • Reevaluation of the pilot study data

36. Cultural issues in providing care Refugee family with a sick child:An accident Mother Father Psychologist Midwife Son 7m.o. Nurse Child Protection Physical therapist Interpreter

37. Balancing incompetence and skill: collaboration Issues related to our culture • Our cultural push to explain, understand • Our cultural push to prepare, be in control • Our difficulty to accept irreversible loss • Our guilt reaction • Our tendency to trust rules more than feelings

38. Balancing incompetence and skill: collaboration • Working with other cultures gives us an opportunity to look at our culture • Often we assume that we are “normal” and they are “cultural” • Understanding our own culture and working with equally important • The fact that our culture represents the system may not mean it’s “normal”

39. Balancing incompetence and skill: collaboration What do we do? • Try to separate “cultural” issues from other problems • Use professional interpreters whenever possible • Look at yourself and you will find both differences and similarities • Use both similarities and differences to learn, understand, connect, develop trust, and help

40. New American Families and Social Systems Refugee family with a dying mother Mother Father MD Nurse Son 48 Son 42 Son 40 . Patient advocate Nurse Nurse Psychologist Chair of Ethics Committee

41. Clinical strategies • Three most important components of successful cross-cultural care: • Rapport • Rapport • Rapport

42. Clinical strategies Effective ways of establishing rapport: • Developing curiosity • Deconstructing therapy • Working with “resistance” • Accessing non-verbal dimensions of your encounter • Accepting and utilizing your cultural incompetence

43. Applying clinical strategies • We can be competent in other dimensions of our encounter to compensate for incompetence in certain dimensions (reality check, metacommunication)