Cultural Competency

Cross Cultural Issues and Trauma

    Definition of a traumatic event

A traumatic event is any event or events, which overwhelms our core capacity to cope.

It results in an experience of personal threat to our safety and/or the integrity of our identity.

Complex Trauma Multiple and/or chronic

exposure to developmentally adverse interpersonal victimization

physical, sexual and emotional abuse and neglect

domestic and community violence

War

What Constitutes Cultural Diversity?

Is Vermont Diverse? Diversity

Racial Ethnic Religious Immigrant/refugee status Sexual orientation Living in rural areas Disabled youth Socio-economic status

Vermont Diversity

Demographics 95.3% of Vermont population is

Caucasian 11% of Burlington population is

non-white 30% of public school children in

Burlington are non-white28 languages are spoken

Socio-Economic Factors

Income/poverty 11.1% of Vermont population lives

below poverty 13% nationally

Caucasian: 13% Black : 27.4% Hispanic: 26% Under 18 : 22%

US Census, 2010

Cultural Competency Organizations and personnel have

values and principles and demonstrate behaviors, attitudes, policies that enable them to work effectively cross culturally.

Have the capacity to: Value diversity Conduct self-assessment Manage the dynamics of difference Acquire and institutionalize cultural

knowledge Adapt to diversity and the cultural

contexts of the communities they serve

Linguistic Competency

Capacity of an organization and its personnel to communicate effectively to persons from diverse populations including:

Limited English proficiency Low literacy skills Individuals with disabilities

Organizational , Cultural, and Linguistic Competence, NCTSN

Linguistically Competent Trauma Informed

Services Bilingual/bicultural staff Cross culture communication

approaches Cultural Brokers Interpreter services Sign language services Print materials in applicable

languages In alternate formats (i.e. Braille, audio) Easy to read, picture and symbol

formats

Rates of Exposure Relative to Diverse Backgrounds

African American adolescents six times more likely to be murdered than white adolescents.

Victimization is higher for people from lower socio-economic backgrounds and urban communities

90% of elementary school children in New Orleans witnessed severe violence

Chicago survey found that 75% of 10-19 yr olds had witnessed a shooting or stabbing

(Raia, J.A., Ph.D, Clinical Quarterly, Nat'l Ctr for PTSD, Fall, 1999)

Rates of Exposure Relative to Diverse

Backgrounds Racial incidents can be traumatic

and have been linked to PTSD among people of color

Communities of color can have higher rates of PTSD than the general population

LGBTQ individuals experience victimization and PTSD at higher rates than the general population(source: Leading Change: A plan for SAMHSA’s Roles and Actions)

Trauma and Homelessness An estimated 1 -1.6 million youth are

homeless (National Alliance to End Homelessness, 2006)

Racial and Ethnic Minorities are overrepresented among homeless youth

3-10% are LGBQI2-S Sexual abuse victims 17- 35% Physical abuse victims 40-60%

(Robertson & Toro, 1999; Jenks, 1994).

Up to 43 percent of homeless adolescent males and 39 percent of adolescent females report being assaulted with a weapon while living on the streets (Whitbeck & Simons, 1990)

Homeless Youth

Runaway and homeless youth with previous histories of both physical and sexual abuse have the most severe psychological conditions

Homeless youth with previous histories of abuse are greatest risk for revictimization (Ryan, Kilmer, et al., 2000).

75 percent of homeless youth use marijuana or other drugs (Kipke, O’Connor,

Palmer, & MacKenzie, 1995; Green, Ennett, & Ringwalt, 1997)

Service Considerations Ensure that agency policies and

procedures are not retraumatizing Universal trauma screening as part of

the intake process Unconditional assistance. Provide

access to lowbarrier services, such as a meal or a hot shower, while they are developing trust.

Consider behavior in the context of their life experiences including their traumatic histories.

Remain available while still setting limits.

Prioritize youths’ immediate needs.

Determine the youths’ strengths and talents Allow homeless youth to make their own

choices whenever possible, including about treatment.

Assess cognitive abilities in order to use appropriate and understandable language.

Assess psychosocial needs and refer them to complementary services to augment treatment.

Offer referrals only to youth friendly agencies.

Tailor interactions and treatment plans to individual needs.

Use of trauma-exposure therapies is discouraged due to high incidence of have comorbid substance abuse disorders and lack adequate support and basic safety (Thompson, McManus, & Voss, 2006).

Attend to co-occurring disorders and other mental health problems that need to be addressed.

Ask about current sleeping arrangements at each treatment session and pace interventions accordingly. Willingness to open up to a mental health provider is often directly correlated to how safe they feel when leaving the service provider’s office.

Engaging and retaining these youth in treatment is challenging, even for the most skilled clinicians.

Use a harm reduction model

Childhood Trauma World-Wide■ In the past decade > 2 million children killed in war. ■ 6 million were wounded ■ One million orphaned ■ More than 300,000 youth serve as child soldiers. ■ Female soldiers often sold in to sexual slavery

(United Nations High Commissioner for Refugees)

Refugee Youth Refugee

A person who is outside his/her country of nationality or habitual residence

Has a well founded fear of persecution because of his/her race, religion, nationality, membership in a particular social group or political opinion

Is unable or unwilling to avail himself/herself of the protection of that county or to return therefor fear of persecution

Half of worlds 20 million refugees are children

Refugee Youth

■ Between 1998 – 2001 more than 1.3 mil. refugees admitted to the U.S.■Approximately 40% were under 18

■ In 2003 more than 10,000 refugees under the age of 18 arrived in the U.S. ■ By 2004 number rose to 15,000 (US

Department of State Bureau of Population, Refugees and Migration).

■By 2008 numbers fell back to approximately 10,000 (BRYCS - Bridging Refugee Youth and Children's Services)

Refugee Youth

■ Between 1998 – 2001 more than 1.3 mil. refugees admitted to the U.S.

■ In 2003 more than 10,000 refugees under the age of 18 arrived in the U.S.

■ By 2004 number rose to 15,000 (US Department of State Bureau of Population, Refugees and Migration).

Phases of Refugee Experience

■ Preflight

Onset of political violence/war

Social upheaval, increased chaos

Limited access to school

Flight Uncertainty Children may be born during this

phase Displacement

Separation from caregivers Resulting increase in vulnerability to

victimization Increase in mental health issues Decreased positive outcomes

Basic needs uncertain Unaccompanied minors:

INS (ICE) may detain unaccompanied minors in INS detention centers or juvenile detention ctrs.

Resettlement

■ New belief systems ■Refugees escaping war and persecution are at higher risk of mental health problems■May encounter Western MH systems for the first time

■ Families may be disruptedNew family roles ■Children as culture brokers

Faster language acquisition Faster assimilation

Traumatic Bereavement

Refugee children may have lost family and friends in violent acts resulting in traumatic reactions. ■ Unable to go through grieving process■ Re-Experiencing ■ Wish for revenge■ Preoccupation with the experience

Traumatic Reaction

Exposure to Trauma

Avoidance/Numbing

Avoiding triggers of trauma

Detached from others

Unable to form relationships

Re-Experiencing

Triggers from daily events

Dwelling on unbidden thoughts, memories, sights

Hyperarousal

Nervousness

Hypervigilence

Exaggerated startle reaction

Insomnia

Refugee Children and PTSD

As many as 75% of refugee children meet criteria for PTSD (Allwood et al., 2002).

Additionally refugee children experience acculturative stress (Berry, 1994: Birman et al., 2002).

Few receive services Need for culturally competent

approaches constitute a barrier to care.

Culture and Trauma: LGBTQ Youth

33% of LGB students reported attempting suicide in the previous year vs. 8% of heterosexual peers reported attempting suicide.

84% of LGBTQ students were called names or had their safety threatened due to their sexual orientation

45% of LGBTQ youth of color experienced verbal harassment and/or physical assault

39% of LGB students and 55 percent of transgender students were shoved or pushed.

LGBTQ Youth and Trauma

64% of LGBTQ students feel unsafe at school. 29% missed one or more days of school because they felt in danger.

25-40% of homeless youth may identify as LGBTQ. Parents or caregivers may force them out of their homes after discovering their child’s sexual orientation.

LGBTQ Youth & Trauma LGBTQ youth experience and are

exposed to trauma in many ways: Physical and emotional assaults for

“coming out,” or fear of being found out on a daily basis.

Engaging in at-risk behaviors as a way to cope with confusion about their sexual identity.

Barriers to finding a safe and trusted relationship as disclosure may put them at further risk of harm.

The trauma of this "double bind" underscores the need for confidentiality and safety from a trusted helper.

Trauma and Deaf Children

Deaf children are at increased risk for traumatization. The ongoing communication barriers that often exist within the family and in other key settings can cause: Increased frustration by adults and

children; Difficulty in teaching deaf children

about safety; A lack of educational resources such as

safety curricula and sexual abuse/kidnapping prevention programs

Assumptions by perpetrators that deaf children are less able to disclose information about abuse

Difficulties in teaching/learning skill building and socialization

Decreased opportunities for incidental learning;

Decreased opportunities for trusting, open relationships;

Less disclosure of abuse to caregivers; and

Less understanding of the parameters of healthy/safe touching.

Deaf people may also experience additional communication barriers misunderstanding, and fear during the disclosure or

investigation of a traumatic eventExacerbated feelings of isolation and difference after a traumatic event.

Service Considerations Find a certified interpreter that can

commit to working with the deaf client. Get details about history of hearing loss

and social emotional development. Assess history of language use and

ability to communicate in multiple settings.

Ask about educational background and school settings.

Find out about the availability of culturally relevant supports.

■Be aware of the oppression, stigmatization, and isolation that deaf people often face.

■Consult with specialized providers about bringing a culturally affirming view of deafness into the work

■Find out about the family’s past experiences with therapy and interpreters.

■Working w/ an interpreter:

■Prepare the interpreter for traumatic content ■ Debrief with the interpreter after each session.

Arrange physical placement to maximize your direct eye contact with client.

Look and speak directly to the deaf individual, not the interpreter.

Work with the interpreter to repeat or rephrase as necessary to ensure the client’s understanding.

Remember that the interpreter has an ethical obligation to interpret all that is said in the room.

Interpreter’s own history could affect his/her ability to interpret accurately; personal issues could lead to a violation of boundaries or a dual relationship between the client and interpreter.

Adapting individual child sessions

Modify relaxation techniques to focus on visual and tactile aspects.

A trauma narrative may need to be done with a more visual medium than writing.

The therapist and interpreter together may need to teach the child and family appropriate signs

and words for what has happened to them.

The therapist may need to put more emphasis on increasing socialization skills and safety.

Effects of Exposure to Trauma

Dissociation. Some traumatized children experience a feeling of detachment or depersonalization, as if they are “observing” something happening to them that is unreal.

Behavioral control. Traumatized children can show poor impulse control, self-destructive behavior, and aggression towards others.

Cognition. Traumatized children can have problems focusing on and completing tasks, or planning for and anticipating future events. Some exhibit learning difficulties and problems with language development.

Self-concept. Traumatized children frequently suffer from disturbed body image, low self-esteem, shame, and guilt.

Trauma Informed System

Trauma-informed services are not designed to treat symptoms or syndromes related to abuse or trauma. Instead, the primary purpose is to deliver mental health, addictions, housing supports, vocational or employment counseling services, etc., in a manner that acknowledges the role that violence and victimization play in the lives of most consumers of mental health and substance abuse services.

Trauma Informed System

This understanding is used to design service systems that accommodate the vulnerabilities of trauma survivors and allow services to be delivered in a way that will facilitate consumer participation that is appropriate and helpful to the special needs of trauma survivors.

Harris, M., & Fallot, R. EDS. (2001) Using trauma Theory to Design Service Systems, Jossey-Bass, San Francisco.

■ RICH:

Respect

Information

Connection

Hope

■Empowering and Collaborative Relationships

Risking Connection, Karen Saakvitne

• (

What Works

What Works

■ Power

■ Choice

■ Control

Harris, M., & Fallot, R. EDS. (2001) Using trauma Theory to Design Service Systems, Jossey-Bass, San Francisco.

How Can a Teacher Help? Provide a stable, predictable,

comforting environment Provide clear, consistent rules

and expectations Signal that you are available to

listen Never pressure a student to tell

his/her story Provide opportunities for students

to tell their storyRemember that ‘bad behavior’ may

be a traumatic reaction

Trauma Informed & Culturally Competent

Provide Access to Tutors Display welcome signs in

different languages Display photographs/items from

different countries represented in the student body

Have general class discussion about prejudice and stereotypes