The HIV Mental Health Training Project Columbia University

1. The HIV Mental Health Training Project Columbia University Working with Special Populations & Cultural Proficiency Milton L. Wainberg, M.D. Assistant Clinical Professor Psychiatry

2. Working with Special Populationsin HIV Epidemic • Racial & Ethnic Minorities • Women • Substance Users • Gay/Lesbian/Bisexual/Transgender • Adolescents • Female • MSM

3. Creating Stable ChangeTranstheoretical Model  Precontemplation        THIS APPLIES TO BOTH OUR CLIENTS AND OURSELVES

4. First… A couple of exercises… • Close your eyes • Close your eyes again • A walk across

5. Incorporating Culture into Health • Individual patient-provider & system levels • Culture influences help seeking behaviors and attitudes toward health care provider. • My own experience: 2 Latina patients • Communication must be clear. • Patients have personal experiences of biases within health care systems. • Health care providers from culturally and linguistically diverse groups are under-represented in the current service delivery system.

6. From Cultural Destructiveness to Cultural ProficiencyGeorgetown University’s Child Development Center • Six-part continuum: destructiveness, incapacity, blindness, pre-competence, competence, and proficiency. • Cultural Destructiveness: • people’s trust has been betrayed by neglecting to fully inform them of medical risks and benefits. • A 1989-1991 CDC, Kaiser Permanente, and LA County Department of Health Services measles vaccine study. Parents were never informed that one to the vaccines used was an experimental vaccine and not licensed for sale in the US

7. Not too Good… • Cultural Incapacity: • agencies do not intentionally seek to be culturally destructive but rather have no capacity to help clients from other cultures. • Cultural Blindness: • the predominant system - express philosophy of being unbiased: “belief that color or culture makes no difference and that all people are the same.” • Making services so ethnocentric as to render them useless to all but the most assimilated people from other cultures.

8. Middle Range… • Cultural Pre-Competence: • Hiring staff that reflects a different culture • Exploring how to reach underserved populations • Offering training for their workers on cultural sensitivity • Conducting needs assessments concerning racial and ethnic communities • Recruiting diverse individuals for their boards of directors or advisory committees

9. Slightly Better… • Culturally Competent: • Respect for difference • Continuing self-assessment regarding culture • Continuous expansion of cultural knowledge and resources • Adaptations of service models to meet the needs of different groups • Groups have subgroups, each with important cultural characteristics. • Hire unbiased employees • Seek advice/consultation from clients. • Seek staff who represent the communities being served and who are committed to their community • Provide support for staff - comfortable working in cross-cultural situations. • Policies must enhance services to a diverse clientele.

10. Cultural Proficiency • Holding culture in high esteem - more than provide unbiased care. • Value the positive role culture can play in a person’s health and well-being. • Add to the knowledge by: • conducting original research, • developing new therapeutic approaches based on culture, and • publishing and disseminating the results of their research and demonstration projects. • Advocate for cultural proficiency throughout the health care system and for improved relations between cultures throughout society. • Role models (institutional and patient-provider level) close cultural gaps and improve service delivery (even provider and patient don’t speak the same language)

11. NegativeLevels: Repulsion Pity Tolerance Acceptance PositiveLevels: Support Admiration Appreciation Nurturance Attitudes …

12. Mental Health Consequences • Depression • Anxiety • Suicidality • Internalized Self-Hatred • Low Self-Esteem • Substance Abuse

13. Associations Between Health Risk Behaviors and Self-report of Lesbian, Gay, or Bisexual (LGB) Orientation (adapted from Garofalo et al., 1998) Behavior LGB% non-LGB% Weapon carrying (30 days) 46.3 19.8 Gun carrying (30 days) 24.7 4.9 Weapon in school (30 days) 25.3 8.9 Smoked cigarette (<age 13) 47.9 23.4 Smoked cigarette (30 days) 59.3 35.2 Smoked at school (30 days) 37.4 18.4 Smokeless tobacco (30 days) 33.7 7.7 Alcohol use (<age 13) 59.1 30.4 Alcohol use (life) 86.8 79.0 Alcohol use (30 days) 89.4 52.8 Binge drinking (30 days) 46.2 33.0 Alcohol use at school (30 days) 25.0 6.2 Marijuana use (life) 68.5 47.4 Marijuana use (30 days) 53.7 31.4 Marijuana at school (30 days) 31.6 10.7

14. “Although… gay, lesbian, and bisexual youth (do) show statistically significant elevations in present suicidality, depression, and hopelessness, these differences appear to (be) consequential to the effects of stress, social support, and coping through acceptance” (Safren & Heimberg, 1999).

15. Ethnic Minority Gay Youth Issues(Ryan & Futterman, 1998)

16. Case Study: Interviewing… Adam: “Doc, I’ve been messing around wt Steve” Doc: “What does that mean?” A: “We have been having sex” D: “Are you enjoying it?” A: “Sort of, yeah!” D: “Great. What about condoms? Are you guys using them” A: “ Sometimes…” D: “So, sometimes you use them, that is good, but sometimes it is hard to use them. Let’s figure out what helps you use them and what stands in the way of using them. Let’s do that as you show me how you would use this condom using this plastic penis…

17. Day to Day work… • Get to know all your patients, each as an individual, understand them – feel free to ask! • Know your role • “None of your business!” (religion, sexuality, etc.) • Adjust to them, not the other way around – if uncomfortable, get supervision • We all have experience prejudices – connect with that • Work on your own prejudices – we all have them • However, not over identify – at times the medicine can be worst than the disease!