Cultural Elements in Community Defined Evidence-Based Programs

1. Cultural Elements in Community Defined Evidence-Based Programs NYS OMH Nathan Kline Institute of Psychiatric Research Center of Excellence in Culturally Competent Mental Health Carole Siegel, Ph.D. Gary Haugland, M.A. Lenora Reid-Rose, MBA

2. Definitions • Cultural competency (CC) • At the organizational level by • Policies and procedures in place to enable caregivers to work effectively and efficiently in multi-cultural situations • At the staff level • Attitudes, behaviors, skills and knowledge with respect to cultural groups of staff that enable them to work effectively and efficiently in multi-cultural situations. GOAL of CC: to provide high quality, accessible and appropriate services to cultural groups to reduce service disparities.

3. Definitions • Program • A bundle of services provided within a modality of care • Evidence Based • A program that has established evidence of its effectiveness from multiple controlled trials or quasi-experimental research studies. • Community Defined Evidence (from promising, grass-roots programs) • A program that has evidence of its effectiveness from either non-research based evaluations, small research studies, or from community based support, longevity and endorsement. 

4. Definitions • Cultural infusion • The introduction of modifications and accommodations to a program to reflect a cultural group’s attitudes, customs and beliefs with the goal of improving its acceptance and effectiveness for the group. • Cultural success • Evidence of acceptability of program as measured by • Longevity with funding available • Consumer endorsement • Consumer referrals • Cultural group specific measures of successful outcomes • Standard measures of successful outcomes

5. Project • Study of three community defined evidence-based programs • Documentation of cultural features of programs • Determination of cross-cutting themes of ‘cultural infusion’

6. Aims of project • To gain knowledge of the cultural features of community defined evidence based programs that could be infused into any program serving multicultural populations • To disseminate findings in the form of: • CC training materials for program directors and providers • Replication guide for all or parts of the programs

7. Study Contributors Project Directors Gary Haugland, MA, Lenora Reid-Rose, MBA Field Staff Supervision Kim Hopper, PhD Coordinating Writers Gary Haugland, MA, Carole Siegel, Ph.D. Rachel Levenson, BA PASS Program Project Director Lenora Reid-Rose, MBA Field Staff Jennifer C. Hernandez, MPA , Terese Lawinski, PhD, Katie O’Callaghan, MPA, James Railey, LMSW ,Erick Castellanos, PhD, PASS Staff Nancy Sung Shelton, MA ,William R. Harris Site Facilitators Neville B. Morris, MBA, Colin Dublin, MBA ,Ethel Davis Chambers, RN, Ulysses Harrell Latino Treatment Program at Bellevue Project Director: Gary Haugland, MA Field Staff Terese Lawinski, PhD, Jennifer C. Hernandez, MPA, Erick Castellanos PhD LTP Staff Antonio Abad, MD, Annika Sweetland, LMSW Site Facilitators Manuel Trujillo, MD, Mariano Rey, MD, Hamilton-Madison House Programs Project Director Gary Haugland, MA Field Staff Yu Wen Chou, PsyD , Gary Yu, MPH HMH Staff Pei-Chen Hsu, PhD, Deborah Lee, Yi Wang, EdM Site Facilitators Peter Yee, LMSW,

8. PASSPrevention, Access, Self-empowerment and Support Lenora Reid-Rose, MBA; Neville Morris, MBA; Ethel Chambers, MSW, RN • Population: 13 - 17 year olds with behavioral and emotional challenges and their family members • Goal: to improve youth psychosocial, educational, and community outcomes and family interactions • Approach: • strength-based, self-efficacy focus • youth friendly semi-structured 19 module curriculum flexibly delivered • delivered by adult and peer-mentors with participation from skilled community members • year round supports to youth and families

9. Program Outcomes • Youths have greater skills and more confidence • Youths retain their identities but move towards ‘outside’ world

10. Bellevue Latino Treatment ProgramAntonio Abad, MD;Annika Sweetland, MSW, MPH • Population: Adult Latino inpatients • Setting: 19-bed psychiatric inpatient unit at Bellevue Hospital Center, the largest public hospital in New York City (NYC). • Approach: • Works under the rules of operation of other inpatient psychiatric units at Bellevue with the goals of medication stabilization and return to community • Modifies standard approaches and introduce new modalities to improve the acceptability of and effectiveness of treatments for Latino populations

11. Latino Treatment ProgramFamily, religious and community connections

12. Hamilton-Madison House (HMH)Behavioral Health ServicesPeter Yee, MSW;Pei-Chen Hsu, Ph.D. • Population: Chinese outpatients • Setting: Agency that provides clinical and support services to the Asian population in New York City • Programs studied for Chinese population: • The Continuing Day Treatment Program, • The Chinatown Family Consultation Center • Depression Screening at its Senior Center • Approach: • Modifies standard approaches to improve the acceptability of and effectiveness of care for Chinese populations

13. Hamilton Madison Community Settlement House • Ties together community and mental health services for Asian populations

14. Methods • Semi-structured framework • Field observations and direct interviews of clients and staff • Focus/discussion groups of clients, families and staff • Data collection was dynamic • additional data collected based upon knowledge learned

15. Cultural Highlights: PASS • Establishes a safe, neutral, culturally welcoming environment • Reassurance to parents in a weekend in a comfortable setting, exposing them to the curriculum, mentors, staff participating in workshop activities; learning from special speakers • Weekends in hotel settings for kids, with other activity sites available • Music played, slides shown , and acceptable activities of youth conducted • Chaperones • Establishes trust • No youth expelled • Confidential sessions of youths are sacrosanct • Turns negative events into ‘teaching moments’ • Mentor relationships continue year-round

16. Cultural Highlights: PASS • Utilizes but improves communication styles of youth and families • Levels hierarchical relationship between program staff and youth • Uses language of youths along with language of outside world • Uses language of hope and recovery drawing on spiritual heritage of many • Modifies cultural style of home communication so that parent and child can better communicate • Uses adult and peer role mentors • Adult and peer mentors embody achievable success and illustrate the lessons of the curriculum • Adult mentors drawn from all walks of lives • Peer mentors are program graduates

17. Cultural Highlights: Latino Treatment Program STAFF • Bilingual and bicultural • Virtually all staff from a Latino cultural group and speak Spanish • Have a collective knowledge of diverse cultural expressions • Able to differentiate cultural expressions from symptoms of psychosis, mania or delusions • Peer counselor is a professional Latina • Well accepted and reinforces possibility of personal recovery • Understands fears of patients regarding medications in cultural terms • Conducts an inclusive spirituality groups that recognizes Latinos religious and spiritual connections

18. Unit creates family and involves family • Familismo on the Unit • Warm and friendly ambience characterized by familismo, • Familismo - a culturally specific communication style typical among Latinos and oriented towards family • Community meetings • Daily meetings of staff and patients endorse ‘familismo’ and act to reduce the stress of being hospitalized and extruded from community • Family involvement • Latino families are seen as a natural resource in the recovery process. • Latino families are encouraged to visit from the time of admission, rather than only when the person is nearing discharge (which distinguishes the LTP from other units ) • Outreach to estranged families

19. Treatment modalities modified to work with Latino persons • Family psycho-education program modified to be more accommodating of Latino families • Spirituality group works both as group therapy enhancing medication compliance and to incorporate spirituality into the healing process • Alternative treatments are reviewed for acceptability with treatment regimen

20. Cultural Highlights: Hamilton Madison House • Language accommodation • Staff are from multiple Chinese cultures. Some recruited from abroad. • Establishing trust and respect for traditional social roles • Staff are respectful and welcoming (almost becoming like another family), to clients and families • Cultural view of age and gender roles are taken into account in the ways in which clients are addressed and received by all levels of program staff. • Family involvement • The family unit includes many generations and extended family members • Staff works to engage the family, convince them of the role of medication in recovery and the dangers of tinkering with prescriptions and doses.  

21. Cultural Highlights: Hamilton Madison House • Modification of Western services • Treatment modalities tailored on a one-on-one basis • Individual therapies are favored over group therapies • Day treatment functions in a class room environment with therapists as teachers and clients as students • Depression screens in Chinese and use expressions regarding ‘sadness’ that are acceptable to Chinese • Reduction of shame and stigma • Staff is aware of the cultural view that mental illness brings shame to entire family. • Education • Privacy respected

22. Common elements of cultural infusion • Trust building • Language/communication accommodations • Passionate/compassionate bilingual/bicultural staff • Culturally friendly milieu • Stigma Reduction • New/modified/flexibly delivered services • Peers engaged in programs from cultural groups • Family involvement • Community involvement