CULTURAL COMPETENCY & MENTAL HEALTH

CULTURAL COMPETENCY & MENTAL HEALTH Joan (Nyala) Cooper, Ph.D. Charles R. Drew University of Medicine & Science Adjunct Assistant Professor, Department of Psychiatry & Human Behavior Consultant, National Minority AIDS Education & Training Center Pacific AIDS Education & Training Center

Objectives This session is intended to assist participants with cultural competency skill building in the area of HIV Mental Health. Participants will have the opportunity to: • explore their present level of acceptance of cultural competency as an important mediating variable in decreasing barriers to the receptivity of HIV mental health services; • use cultural dimensions to understanding HIV risk and treatment seeking behavior; and • apply principles of cultural competency to case studies involving HIV and mental health.

THE BIO-PSYCHOSOCIAL MODEL The Bio-psychosocial model incorporates the three major spheres of biological, psychological, and social into … the context of culture. The Cultural Context

The BIO-PSYCHOSOCIAL MODEL Marilyn Martin, psychiatrist, psychoanalyst and author of Saving Our Last Nerve: The Black Women's Path to Mental Health, speaks on depression and how mental health is innately connected to physical health. (Central Texas African American Family Support Conference – Austin Travis Mental Health Mental Retardation Center, 2003)

HIV AND MENTALHEALTH John Anderson, Ph.D. (2005) states that a solid working knowledge of mental health and substance abuse issues is essential for understanding how to help people protect themselves from HIV infection, how to help those who are already infected from transmitting the virus to others, and how to reduce adverse health consequences among those living with HIV. He underscores the link between HIV and mental health by citing the results of the Eric Bing, M.D., et. Al.(2001) HCSUS study that examined mental health and substance abuse in a large, nationally-represented probability sample of adults receiving care for HIV in the U.S. Nearly half of the sample screened positive for a mental health disorder. The results also indicate the high proportion of people receiving HIV-related care who also have mental health and substance abuse problems. In addition to their negative impact on quality of life (Sherbourne et al; 2000), mental health and substance use disorders have been consistently associated with increased HIV risk behavior (Hutton et al; 2004; Booth et al; 1999) as well as poor access and adherence to anti-retroviral treatment for HIV/AIDS (Cook et al; 2002; Tucker et al; 2003).

HIV AND MENTAL HEALTH While Anderson states that mental health and substance use disorders are highly treatable, they must first be identified and referred to appropriate services. He finds it unfortunate that “stigma and lack of knowledge about these disorders often prevent this from happening (Cooper et al; 2003; Kessler et al; 2001).” The problem of client under-recognition of mental health problems is compounded when HIV providers lack the experience to adequately assess mental health needs. He states “Primary care providers are not well-equipped to diagnose and treat common mental health disorders (Staab et al; 2001). Additionally, prevention workers and prevention case managers typically receive few guidelines and minimal training in the systematic assessment of mental health and substance use disorders.”

ROLE OF THE MENTAL HEALTH PROFESSIONAL The role of the front line mental health professional treating persons with mental illness and HIV/AIDS has become more complex as the disease and the treatment for it changes. • Prevention Strategies • Differential Diagnosis • Mental Health Treatment • Psychiatric Rehabilitation • Community Outreach • Systems Consultation • Research

CHALLENGES TO HIV/AIDS IN PERSONS WITH MENTAL ILLNESS Persons with mental illness are often at greater risk for HIV infection and progression than the general population because of the characteristics of their illness. Those with severe, chronic (CMI), or serious and persistent mental Illness (SPMI) have increased risk due to: • Periodically Impaired Judgment • Periodically Impaired Cognitive Functioning • Misinformation about Condom Use • Difficulty following Clean Needle Precautions • The Most Vulnerable of the Homeless • Poverty and Community Environment • Inadequate Professional Care • Alcohol and Other Drug Abuse (HOPE Curriculum, APA, 2000)

HIVCOUNSELOR PERSPECTIVES, Vol.13, 2, 2004 CULTURAL COMPETENCE AND HIV People with HIV and people at highest risk for HIV are diverse, in terms of everything from race and ethnicity, gender, and sexual orientation, to age and socioeconomic status. Since HIV counselors must explore particularly sensitive issues – including sexual activity, substance use, and disease – it is crucial that counseling be well-grounded in concepts of cultural competence. The issue reviews definitions of cultural competency and the ways in which cultural competence is consistent with and builds upon client-centered counseling skills and a counselor’s willingness to learn from clients.

Some Issues in “Cultural Competency” HIV Counselor Perspectives (April, 2004) states that there are two main schools of thought about cultural competence. They relate that the first suggests that counselors should learn beliefs and norms of the specific cultures they are working with and mirror those cultures (Wilson,& Miller, 2003; Snowden & Jerrell, 2003). The second suggests that culturally competent counselors focus on learning skills such as openness and active listening that allow them to uncover an individual client’s culture and level of acculturation in the course of the counseling sessions (Fullilove, M, 1998; Houston-Hamilton, A., 1998; Jue, S. 1988; and HRSA, 2001). The authors further indicate that recently, researchers have re-examined how counselors and practitioners view “culture” and the cultural models on which prevention strategies are built. In their examination, Airhihenbuwa et al; 2000 and Yoshikawa et al; 2003 look at the models and definitions to see how they may perpetuate the perception that clients who are different are “outsiders” and how this perception may impede efforts to reach those in need of service.

Definitions Culture is a set of shared behaviors, ideas and values which are symbolic, systematic, cumulative and transmitted from generation to generation. (L.A. County, Dept. of Health Services) “Culture is a particular set of values, norms, attitudes, and expectations about the world that shapes the personalities of those reared in that culture.” (Marin, 1991) Cultural Competency has been defined as a “set of academic and interpersonal skills that allow individuals to increase their understanding and appreciation of cultural differences and similarities within, among, and between groups.” (L.A. County, Dept. of Health Services)

BACK TO MARIN’S DEFINITION OF CULTURE The authors of “Cultural Competence and HIV” state that Marin’s definition of culture avoids the problem that others have identified: in the HIV prevention field, as in other areas, “culture” may refer only to racial and ethnic minority status, even though White and heterosexual people, for example, were also raised with values, norms, attitudes, and expectations (Wilson, 2003). They further state that others warn that when only non-European peoples are seen as having “culture,” their non-European ways are defined as barriers to their progress, subtly linking the ideas of “culture” and “barrier” (Houston-Hamilton, 1998; Airhihenbuwa et al, 2003). They identify a third category of “others” who suggest that culture is influenced not only by race or ethnic background but also by other demographic factors such as age, socioeconomic or immigration status, sexual orientation, and history of oppression (Brooks et al, 2003; Diaz, et al, 2000).

DIMENSIONS OF CULTURAL DIVERSITY Primary Dimensions 1. Age 2. Ethnicity 3. Gender 4. Race 5. Language 6. Physical Abilities and Qualities 7. Sexual /Affectional Orientation 8. Childhood Experiences and Family Factors (Family religion, place of birth and household location, family social class, parents occupations, etc.)

DIMENSIONS OF CULTURAL DIVERSITY Secondary Dimensions 1. Education 2. Geographic Location 3. Income 4. Marital Status 5. Military Experience 6. Parental Status 7. Religion 8. Work Experience 9. Current Social Class

DIMENSIONS OF CULTURAL DIVERSITY Tertiary Dimensions 1. Experiences with Immigration, Exile, etc. 2. Lifestyle 3. Degree of Assimilation

STAGES OF CULTURAL COMPETENCY 1. Cultural sensitivity or awareness (being conscious of the nuances of other cultures and one’s own culture)…leads to 2. Cultural knowledge (understanding cultural differences, seeking accurate information about a cultural group),…which results in 3. Cultural competency (the fusing of sensitivity and knowledge with behaviors that enhance interaction among persons from varied cultures) (Kavanagh & Kennedy, 1992; Torres,1993)

CULTURAL INFUSION Cultural infusionreflects the extent to which ethnic/cultural characteristics, experiences, norms, values, behavioral patterns and beliefs of a target population, as well as relevant historical, environmental, and social forces, are incorporated in the design, delivery, and evaluation of targeted health promotion materialsand programs.(Myers, Linda James, 2003)

CULTURAL DIMENSIONS OF GREATEST CONCERN • Surface Structure – visual aspects such as language, dress, diet, clothing, music, etc. (Surface Structure usually increases the receptivity, comprehension, or acceptance of messages.) • Deep Structure – values, beliefs, philosophical assumptions, etc. (Deep Structure conveys salience and determines program or message impact.) (Myers, Linda James, 2003)

BARRIERS TO TRUST “Historical racism, sexism, and homophobia, both in society and in the medical establishment, build barriers for many people seeking to access health care, including HIV testing. In particular, there is a legacy of mistrust around the treatment of sexual issues by the American medical establishment.” - The Tuskegee Study - Sterilization without Knowledge or consent Racism, sexism, and homophobia can have powerful effects on: - self-esteem - communication style - body image - feelings of control which in turn, can diminish a client’s sense of - self-protection, - ability to negotiate - and capacity to employ harm reduction strategies.

Erving Goffman, whose seminal work "provides the theoretical underpinnings for much of the literature on stigma and stereotyping" (Health Resources and Services Administration, HIV/AIDS Bureau [HRSA/HAB], 2003), defines stigma as "an attribute that is deeply discrediting" and reduces the stigmatized individual "from a whole and usual person to a tainted, discounted one" (Goffman, 1963, p. 3). HIV infection fits the profile of a condition that carries a high level of stigmatization ... . • First, people infected with HIV are often blamed for their condition and many people believe HIV could be avoided if individuals made better moral decisions. • Second, although HIV is treatable, it is nevertheless a progressive, incurable disease. • Third, HIV transmission is poorly understood by some people in the general population, causing them to feel threatened by the mere presence of the disease. • Finally, although asymptomatic HIV infection can often be concealed, the symptoms of HIV-related illness cannot. HIV-related symptoms may be considered repulsive, ugly, and disruptive to social interaction ... . (HRSA/HAB, 2003) The result is the widely documented phenomenon of HIV-related stigma. "HIV-related stigma refers to all unfavorable attitudes, beliefs, and policies directed toward people perceived to have HIV/AIDS as well as toward their significant others and loved ones, close associates, social groups, and communities. Patterns of prejudice, which include devaluing, discounting, discrediting, and discriminating against these groups of people, play into and strengthen existing social inequalities – especially those of gender, sexuality, and race – that are at the root of HIV-related stigma" (HRSA/HAB, 2003).

SELF-TEST ON CULTURAL COMPETENCE Rate Yourself on a scale of 1 to 5 (1 = low and 5 = high) DOING: How good are you at: • Personalizing observations (using "I" not "you" messages) • Paying attention to your feelings (seeking to understand your own reactions better) • Listening carefully (paying attention to verbal and non-verbal content) • Observing attentively (watching the client's repeated behaviors to try to understand the meaning of those behaviors) • Assuming complexity (recognizing that multiple perspectives and outcomes exist) • Tolerating ambiguity (responding to unpredictable situations without getting stressed or cranky) • Having patience (staying calm, stable and persistent in trying situations) • Managing personal biases (recognizing that everyone belongs to many groups and no one represents a group)

SELF-TEST ON CULTURAL COMPETENCE (continued) BEING: How good are you at: • Being non-judgmental (stopping the tendency to negatively judge others who are different) • Being flexible (readjusting quickly and effectively to changing situations) • Being resourceful (responding skillfully and promptly in new, uncertain situations) • Having a sense of humor (laughing at oneself and with--not at--others; finding humor in the irony of life) • Showing respect (honoring others who are different) • Displaying empathy (feeling the thoughts, attitudes and experiences of another) Total score: ____ Scores 70 to 61 = highly competent Scores 60 to 51 = moderately competent Scores 50 & below = need more practice Revised by Dr. Mikel Hogan Garcia. California State University at Fullerton. in 1990 from materials developed by C. Dodd and F. MontaJzo. Intercultural Skills For Multicultural Societies (1987) and G. Ferraro. The Cultural Dimension of International Business (1990).

“FOLLOWING CLIENTS TOWARD COMPETENCE” • Fullilove, M. 1998; Houston-Hamilton & Day, 1998; and Jue, S, 1988 suggest that counselors take an approach that focuses on the client’s experience of his or her background and present situation. This encourages practitioners to shed the idea that the client whose culture is different from the counselor’s is “other” and to challenge any stereotypes or assumptions that the counselor may have about this “other” culture. As repeated in the APA HOPE Curriculum, Hamilton & Day offer four steps to “working downhill” in HIV counseling: • Find ways to regularly acknowledge to self and client that each individual has both cultural and personal histories and that these are integral to a sense of self and a shared world view; • Incorporate a full range of sensory information and expressive resources to uncover the style and medium that make prevention (and treatment)) messages most accessible, understandable, and acceptable to the client; • Modify (prevention) messages, modes, and materials as new information emerges that may make culturally-based concepts clearer to individuals with different world views; and • Account for cultural dynamics on both sides of the table.

CASE STUDY [This case study is taken from “Cultural Competence and HIV,” HIV Counselor Perspectives, Vol. 13, 2, April 2004.] Case Study At the end of a busy antibody test counseling shift, Gloria, a 37-year-old African American test counselor looks up to see Susan, a 24-year-old White woman and a new counselor, leaning against the doorframe and looking uncomfortable. Gloria, an experienced counselor, invites Susan in and asks her how her last session went. "She was negative, thank God," Susan says. "But, there were a couple things I wanted to check out with you. I feel kind of stupid, since we just had that class on cultural competence. Do you have time to give me some feedback?" As Susan tells her story, it becomes clear that there were a few snags in Susan's session with Louise, a 65-year old African American woman and first-time tester. "Somehow we got sidetracked onto how the AIDS epidemic got started. At first, I felt really good talking about that, because I know a lot about it and I thought I could build trust by showing I was knowledgeable. But then it started cutting into our risk assessment time and I began to rush through the assessment questions. The client looked offended and got really quiet, and I was really conscious of being this White woman asking her these really personal questions. "Finally I just said ,'I'm new at this and I don't feel like I'm doing a good job connecting with you. Can we go back a few steps? Is there a way I can be more helpful?” Gloria praises Susan's decision to seek consultation. She says that she is familiar with African American clients asking about how AIDS began. 'It sounds like you might have felt a little insecure, and here was a chance to show your credibility, but then you got sidetracked. How do you think it would have been for you to say, 'A lot of people have asked me that, and there are lots of theories. What have you heard? What makes sense to you?'" Susan agrees that this approach could have given her a better window into Louise's world View. Gloria continues, "And you're right to think she might be checking out your credibility. This woman lived through Tuskegee. Still, remember to move on: everybody has a story, and listening to that story can take us to the next step, but stay focused on the client's risk-related needs." "Another thing that I noticed was that you said you got rushed doing the risk assessment questions," Gloria observes. "Remember, you aren't just a White woman and a stranger: you're young enough to be her daughter. And she has never tested before. She's new to our 'culture.' Maybe going through the risk assessment abruptly felt intrusive. Sometimes, I introduce the assessment by saying, 'I'd like your permission to ask you some personal questions about things like sex and drugs. Your answers are confidential, and I hope we can use them to identify some steps that will help you protect your health. “Probably the most important thing you can do with any client is to show respect and a willingness to listen." Gloria adds, ''It sounds like you already know that, because your gut told you things weren't working out and that you needed to reconnect with Louise. What happened when you acknowledged the problem and asked Louise what you could do to connect better?" Susan says that Louise became a little tearful as she recounted how a friend from church had lost a son to AIDS. As Susan eased back into the risk assessment, Louise shared more openly. "She even ended up taking some textured condoms to use with her 'special friend. 'I was a little surprised those would catch her eye." Gloria says, "So you were able to recover, and Louise helped you see where she needed to go next Remember, our clients don't expect us to know everything about AIDS or about them. Be interested and learn all you can in the time that you have." Gloria grins, 'We'll talk about your assumptions about senior citizens and sex next time."

CASE STUDY DISCUSSION

BE SAFE: Another Model for Cultural Competency Dr. John McNeil (2004) A panel of multidisciplinary and multi-Diaspora healthcare providers developed a model for dealing with minority patients infected with HIV. Process steps include: Workshop; Literature search; Model development; Focus group feedback. Model Development BARRIERS TO CARE - ETHICS - SENSITIVITY OF PROVIDER - ASSESSMENT - FACTS - ENCOUNTERS -

Talking with a Patient Whose Native Language May be Different from Yours* Improving communication skills is moving toward cultural competence. When an appropriate native speaker is not available, an English speaking therapist may have to see the client. Patients whose English is limited report that they take many cues from the listener's face. They report that a good listener: • Smiles and looks interested. • Is patient. • Is cautious about humor which new English speakers may find hard to understand. • Listens carefully.

Basic Do's of Communicating with limited-English Speakers • Make your statements as specific as possible. • Make your statement in a variety of ways, to multiply the chances of getting the thought across. • Keep pencil and paper handy. Use them to write key information for the client. • Watch for responses that indicate real understanding. • Use body language to illustrate what your words say. • Avoid contractions. • Use the vocabulary that the client has used. They are words s/he understands. • Ask the client to write down any words that you have trouble understanding. • Give general information before dealing with specific issues.

Basic Do's of Communicating with limited-English speakers • Let the patient see your lips as you speak. • Smile. • Be aware of your assumptions. • Don't rush. Be patient. • Listen carefully. • Speak a little more slowly than usual, but not more loudly. • Be careful with your pronunciation. • Stick to the main points. • Emphasize key words. • Avoid jargon. • Use simple sentence structure.

Basic Do's of Communicating with limited-English speakers Other Hints • Avoid asking whether the patient understands. The person is not likely to admit not understanding. Instead, ask the client to repeat back to you the information you want the client to remember or act upon. • A limited-English speaker's native language may not have words for "could," "might," or "may." • To the patient, it may sound demanding to say "should." If the statement seems not to fit the situation, use other words to clarify. *Derived from the County of Los Angeles Commission on Human Relations booklet "How to Communicate Better with Clients. Customers and Workers Whose English is Limited," (Developed by Carole Chan). SUMMARY & CLOSING COMMENTS

CULTURAL COMPETENCY & MENTAL HEALTH