CULTURAL ASPECTS OF MENTAL HEALTH

1. CULTURAL ASPECTS OF MENTAL HEALTH Mareasa R. Isaacs, Ph.D. Mental Health Preconference American Academy of Pediatrics July 28, 2011

2. Disclaimers • “I have no relevant financial relationships with the manufacturer(s) of any commercial product(s) and/or provider of commercial services discussed in this CME activity.” • I do not intend to discuss an unapproved/investigative use of a commercial product/device in my presentation.

3. Purpose • To briefly define culture & examine its importance. • To describe issues within mental health systems that are often determined by culture. • To delineate the importance of developing more culturally competent professionals and systems.

4. Conclusion A fundamental weakness of mental health systems is the failure to recognize the importance of CULTURE in the epidemiology, conceptualization, treatment, recovery, and prevention of mental health problems. Mental Health: Culture, Race & Ethnicity, A Supplement to the Surgeon General’s Report, 2001.

5. What Is Culture? Culture is “the integrated pattern of human behavior that includes thoughts, communication, actions, customs, beliefs, values, and institutions of a racial. ethnic, religious, or social group”. Source: Cross, Bazron, Dennis & Isaacs. (1989). Towards A Culturally Competent System of Care.

6. Why Is Culture Important? Culture represents the “vast structure of behaviors, ideas, attitudes, values, habits, beliefs, customs, language, rituals, ceremonies, and practices “PECULIAR” to a particular group of people, and it provides them with: • A general design for living, and • Patterns for interpreting reality. Source: Wade Nobles, (1985). Africanity and the Black Family. An unpublished paper.

7. Characteristics of Culture • Every human being has a culture. • Culture is learned. • Culture is dynamic and creative. • Some aspects of culture are shared by large groups, while other aspects may be the creation of smaller groups. • Most people belong to many different cultures and subcultures. • Culture can be viewed as a “protective” factor. • Almost all societies create some type of hierarchy of cultures.

8. Layers of Culture • A National level • A Regional level • A Racial/Ethnic affiliation level (includes linguistic) • A Religious/Spiritual level • A Gender/Sexual Orientation level • A Generation level • A Social Class level • A Profession/Career level

9. Example: The Common Cold Think about when you have a bad cold. There were probably things that your mother, grandmother, or other adults suggested that you take to get rid of it and to help you feel better. These are remedies, in addition to the usual pharmacy cough drops, cough syrup, or pills. • What were some of the remedies recommended by members of your family?

10. Self Actualization Esteem and Identity Love and Belonging Safety and Security Physiologic (Food, Water) Maslow’s Hierarchy of Needs(Based on 1943 Theory of Human Motivation)

11. PRESIDENT’S NEW FREEDOM COMMISSION GOAL 3: DISPARITIES IN MENTAL HEALTH ARE ELIMINATED! • Minorities are underserved in current system • Minorities face barriers to receiving appropriate mental health care • Cultural issues also impact service providers • Rural America needs improved access to mental health care Achieving the Promise: Transforming Mental Health in America, 2003

12. THE CONTEXT FOR DISPARITIES • RACE and ETHNICITY matter • Concentration of POVERTY • Geographic LOCATION matters • Personal and Provider BIASES and ATTITUDES • MEDIA Stereotyping • STIGMA and Lack of Education • Unwillingness/Inability to identify and use STRENGTHS & ASSETS of communities/families of color

13. Fundamental Barriers for Communities of Color • System-induced Barriers • Community-induced Barriers • Culture-induced Barriers

14. 5 CRITICAL DIMENSIONS OF SERVICE SYSTEMS • ACCESS: Mechanisms that facilitate entering, navigating & exiting appropriate services and supports as needed • AVAILABILITY: Having services & supports in sufficient number and capacity to meet the needs of the populations served • UTILIZATION: The rate of the use of services or their usablity for populations served • QUALITY: The degree to which services & supports increase the likelihood of desired outcomes and are consistent with current professional knowledge • OUTCOMES: Improvements in levels of functioning and perceived well-being Source: Hernandez et al (2006), Study 5: Improving Cultural Competence in Children’s Mental Health: Making Services Work Series;

15. Definition of Cultural Competence Cultural competence is a set of problem-solving skills that includes • the ability to recognize and understand the dynamic interplay between the heritage and adaptation dimensions of culture in shaping human behavior; • the ability to use the knowledge acquired about an individual’s heritage and adaptation challenges to maximize the effectiveness of assessment, diagnosis, and treatment; and • internalization (i.e., incorporation into one’s clinical problem-solving repertoire) of this process of recognition, acquisition, and use of cultural dynamics so that it can be routinely applied to diverse groups, professionals, and consumers to work effectively in cross-cultural situations. Source: Whaley & Davis. (2007), Definition developed for the Hogg Foundation’s Cultural Competence Initiative.

16. 5 Elements of Cultural Competence Values Diversity • awareness and acceptance of differences in communication, world view, and definition of health and family Cultural Self-Assessment • able to assess itself and have a sense of one’s own culture and relationship to others Manages the Dynamics of Difference • understands that both the client and service provider bring culturally prescribed patterns of communication, etiquette, and problem solving styles to the situation • also different histories & experiences Institutionalizes Cultural Knowledge • Sanctions and/or mandates the incorporation of cultural knowledge m Adaptation to Diversity • makes adjustments to create a better fit between client and service through adaptations of policies, structure, values, and services Source: Cross, Bazron, Dennis & Isaacs. (1989). Towards A Culturally Competent System of Care.

17. ESSENTIAL SKILLS NEEDED FOR CULTURAL COMPETENCE • Ability to communicate accurate information • Ability to communicate using the language of the client • Techniques for learning the cultures of groups • Ability to openly discuss racial/ethnic differences and issues • Ability to assess the meaning and importance of race/ethnicity for a specific client • Ability to differentiate between the symptoms of individual emotional stress & stress arising from social structures and conditions • Ability to use the concepts of empowerment • Ability to recognize and combat racism, racial stereotypes, and myths Isaacs & Bazron (2000). Training materials for Cultural Competence Training, Pre-Training, Systems of Care Training Institute.

18. Cultural Adaptations in Service Delivery • Changes in the approach to the delivery of the service. • Changes in the nature of the therapeutic relationship. • Changes in location of services. • Changes in the components of the intervention to accommodate cultural beliefs, attitudes and behaviors. • Integration and use of spirituality in the treatment context. • Integration of indigenous healing practices. • Use of social technology (Facebook, twitter, texting, etc.).

19. Organizational Changes to Accommodate Cultural Differences • Changes in staff awareness, knowledge, skills & comfort with identifying and addressing inequities • Change in mission, policies, structures and procedures • Change in staffing patterns and/or staff diversity • Changes in position descriptions and staff performance measures • Changes in community relations and engagement • Changes in communication strategies and mechanisms • Changes in the composition of advisory boards, governance boards, committees • Changes in the array of professional development and training required and offered to staff • Changes in MIS and other data reporting systems and reports Adapted from the National Center for Cultural Competence & Cross et al., 1989

20. Language of problems, disease Focus on deficits Move away from individual Focus on back-door, deep-end Expert knows best Specialized professionals and experts Moves it out of the mental health clinic/hospital domain Focus mostly on mind/brain Language of hope, healing, recovery, resilience Focus on strengths & competencies Move towards family, group, community Focus on front porch, prevention, early intervention Greater client decision-making, choice Social networks made up of many different types of expertise Non-stigmatizing locations like churches, recreation centers, schools, etc. Integration of mind, body, spiritand social context TRANSFORMING MENTAL HEALTH

21. Cultural Competence Is A Journey