Reinventing Ourselves as Mental Health Clinicians When Working with Refugee and Immigrant Populations

October 31, 2008MIAB ConferenceThe $ and Sense of Culturally Effective Care:  Access, Communication, and Commitment

Zarita Araújo-Lane, LICSW

Cross Cultural Communication Systems, Inc.

Tel: (781) 729-3736 ext.105

Email: zaraujo_lane@cccsorg.com

What does this sign tells you?

PERCEPTIONS PERCEPTIONS

Perception Towards Your Assistance

Goals

•To understand your clinical construct

•To understand how to work with  interpreters

•To understand how to engage and treat immigrant and refugee populations

Goal # 1

To understand your clinical construct

Providers vs. Helpersadapted from Randall-David (1989)

Counselors

Psychiatrists

Psychologists

Social Workers

Ministers

Curanderos Ministers Root Workers Vodoo Priests Medicine Men Herbalists Family / Friends Espiritistas

“…mentally ill patients have the right not to be abused but also they have the right to the best available mental health care”

(Adopted by the General Assembly of the United Nations,

1991). Copied: Ethics Culture and Psychiatry by Okasha et al, 2000

Declaration of Madrid,1960-1970Mental Health Programs

Programs need to not only treat and rehabilitate but also promote mental health

A need to develop a collaborative approach with other professional community members and families

A need for strategy ‘s temporal validity. (constant evaluation of short and long term goals)

Copied: Ethics Culture and Psychiatry by Okasha

et al, 2000

Autonomy vs. CollectivismAdapted from Derald Wing Sue and David Sue (2003)

Guilt‘when individuals engage in wrongful behaviors and this is a type of an individual experience’

Shame‘when individuals engage in wrongful behaviors and this is a type of collective (family, friends, community) experience’

STIGMA a FORM of SHAME

How is the community going to perceive the fact that I need Mental Health Services?

How is my family going to perceive the fact that I need Mental Health Services?

Stigma/Shame

“I Must Have Done Something Wrong…”

“I Should Pay for My Sins…”

“There is Nothing You or I Can DO…”

And now EVERYONE in my family and community…

is going to know what I have done!

These are the words of many

patients who were referred to out-patient mental health services for evaluations and treatment.

In Summary:

Patient and or family who may feel shame or guilt and do not seek help

Mental Illness can be perceived as a punishment or bad karma

Patient sees illness in a fatalistic way

Adapted: Clinical Manual for Cultural Psychiatry by Dr. Lim, 2006

Precipitant Factors for Referrals

Chronic illnesses, yearly check-ups Children with academic problems Children with behavioral problems Couples struggling with staying together Alcoholism in the family Mental illness Inability to keep up with work demands

Referral Sources

Community Organizations with key community advocates that speak the patient’s language

Community Health Centers and Pediatricians or Primary Care Physicians

Schools with Special Education Departments

Court Systems and Probation Officers or CAB Emergency Rooms

Other Community Members

Building Trust

Fundamentals of trust

Competence

Sincerity

Involvement

Copied from Business Design Associates, Inc. 2002

We all have a need to feel and express:

Honor is a sense of worth or dignity

that is defined by actions prescribed in a person’s traditions, rituals or history.

Respect

Respect is the acknowledgement

of a person’s roots through a

behavior

Generosity

A willingness to do something out of the ordinary that creates the sense of common ground with another.

Trust

Trust is a feeling or assessment

that is evoked in a person

involved in an interpersonal

interaction. person’s roots

Respect Means Honoring Boundaries

“Respect also means honoring people’s boundaries to the point of protecting them.”

(Copied from Dialogue and the Art of Thinking Together by William Isaacs,1999,

Random House Publishing)

Respect Means Honoring Boundaries

“If you respect someone, you do not intrude.”

(Copied from Dialogue and the Art of Thinking Together by William Isaacs,1999,

Random House Publishing)

Respect Means Honoring Boundaries

“ At the same time, if you respect someone, you do not withhold yourself or distance yourself from them.”

(Copied from Dialogue and the Art of Thinking Together by William

Isaacs,1999, Random House Publishing)

Eliciting the patient’s model of illness as per Dr. Kleinman Dialogue with the patient

What do you think caused your problem?

Why do you think it started when it did?

How bad (severe) do you think your illness is?

What do you think your sickness does to you?

Do you think it will last a long time, or will it be better soon in your opinion?

Dr. Kleinman’s Model

What kind of treatment would you like to have?

What are the most important results you hope to get from treatment?

What are the chief problems your illness has caused you?

What do you fear most about your sickness?

Pay attention to the story!

Use same words as the patient, at first, as a way of showing that you are listening!

Cultural Formulation

cultural identity of the individual

and

cultural explanations of the illness

What is culture?

According to Fergurson ( 1991)

Culture is interactional and dynamic.

(just one aspect of an individual’s identity; along with others aspects such as gender, age, and class)

What is culture?

According to Bonder et all (2002)

Culture is learned.

We are shaped by the belief systems around us.

One is not born with knowledge of a culture

What is culture?Huges (1976) defined culture as a

“learned configuration of images and othersymbolic elements (such as language) widelyshared among members of a given society or

social group which, for individuals, functions as an

orientational framework for behavior.”

Culture

Written Rules- laws, codes, standards

Unwritten rules- mores

World View- a set of assumptions about a person’s environment

What is culture competency?

According to CLAS Standards

Being able to recognize and respond to

health–related beliefs and cultural values, disease incidence and

prevalence and treatment efficiency

What is culture competency?

On-going assessment of how one’s own values interact with the other person’s values.

The ability to live with the fact that there are many sides (truths) to a story.

What is culture competency?

Paying attention to the individual.

Connecting around the other person’s thinking by echoing it.

Transference and Countertransference Issues

Understanding your and the patient’s worldview

TransferenceInterethnic / Intraethnic effects

Overcompliance

Denial of ethnocultural factors

Mistrust

Hostility

Ambivalence

Omniscient-omnipotent therapist

The traitor

Autoracism Ambivalence

Adapted: Clinical Manual for Cultural Psychiatry by Dr. Lim, 2006

Countertransference Interethnic / Intraethnic effects Denial of Etnhocultural

factor

Clinical Anthropologist syndrome

Guilt or pity

Aggression Ambivalence

Overidentification

Distancing

Cultural Myopia

Ambivalence

Anger

Survivor’s guilt

Adapted: Clinical Manual for Cultural Psychiatry by Dr. Lim, 2006

Personality

Internal Dimensions

External Dimensions

Organizational Dimensions

Race

Age

Gender

Ethnicity

Sexual Orientation

Physical ability

Geographic Location

Income

Personal Habits

Recreational Habits

Religion

Educational Background

Work Experience

Appearance

Parental status

Marital status

Functional Level/Classifications

Work Content Field

Division/Department/Unit/Group

Seniority

Work location

Union Affiliation

Management Status

Copied from: Gardenswartz, Lee and Rowe, Anita. Managing Diversity. MC Graw-Hill. 1998

Four Layers of Diversity:Four Layers of Diversity:

Three Culture PatternsDependent Interdependent Independent

Authority (Not Equal, hierarchical)

Equal Equal

Time Circular

(past and present

external control)

Circular and Linear Linear

(present and future, internal control)

Community More important than the individual

Community is important, as is the individual

Individual first, then others

Copied from: Carr-Ruffino, Norma. Managing Diversity. Thomson Publishing's, 1995

Four Character Values by CCCS

Honor

Respect

Generosity

Trust

Developed by CCCS, Inc. 1996

Goal # 2

To understand how to work with  interpreters

Accuracy in Mental Health interpretation

The understanding and conversion of meaning

From source to target language.

The understanding of purpose for session

The understanding of silences

Interpreter Roles Conduit

Clarifier

Culture broker

Patient advocate

Bridging the Gap Manual

The Triadic Relationship

Pre-session

(CIFE)

C onfidentialI first personF lowE verything will be

interpreted

SessionInterpreter

• Manages the flow

• Has good listening skills

• Is able to project voice

• Is able to check-in when in doubt (clarification)

Post- session

• Makes sure that patient understood Interpreter

• Follows patient to the other visits if approved by institution

• Assists scheduling future Appointments

• Requests consult with provider if necessary

Accuracy

No______ omissions additions false fluencies distortions

Goal # 3

To understand how to engage and treat immigrant and refugee populations

Initiating Conversation Towards Trust

Work with patient’s conceptual system regarding the seeking of mental health care services

Negotiate and Compromise

(location, language, gender, confidentiality, interaction in community)

Involve key players

(community, religious, family, work, etc.)

Four Character Values

Honor Respect Generosity Trust

Three Cultural Patterns

Dependent Interdependent Independent

Authority Not Equal Hierarchical

Equal Equal

Time Circularpast + present

external control

Circular and Linear

Linearpresent + future

internal control

Community More important than the individual

Community important,

but so is the individual

Individual first, then others

Somatization

a culturally competent way of communicating:

no separation between body and soul

Providers Building Bridgesbuilding bridges is often an active role

Acknowledge patient’s story by being a good listener

Understand patient’s relationship with the community and the referral source

Stay with the patient’s story and ask for clarification

Providers Building Bridges Empathize with patient’s stigma, shame and fears

Help patient develop strategies to overcome stigma

Acknowledge loss of present role if patient engages in treatment

Explore with patient alternative ways of feeling connected with the community and with his or her role

Providers Building Bridges

Understand patient’s own immigration history

Be flexible

Use story telling as a form of externalization

Providers Building Bridges

You can illicit information, be educated by patient or patient’s representative…

You can coach and negotiate a comfortable compromise…

but you cannot change the value of a stigma or shame without disarming the patient from his or her honor…acknowledge, accept and work with it!

In Summary:

Essential components of culture

Culture is learned. Culture refers to a system of meanings. Culture acts as a shaping template. Culture is taught and reproduced. Culture exists in a constant state of change. Culture includes patterns of both subjective and

objective components of human behavior.

Copied : Clinical Manual for Cultural Psychiatry by Dr. Lim, 2006

DSM-IV-TR Outline for Cultural Formulation

•Cultural identity of the individual

•Cultural factors related to psychosocial environment and levels of functioning

•Cultural elements of the relationship between the individual and the clinician

•Overall cultural assessment for diagnosis and care

Migration History

Pre-migration historyCountry of origin, education, socioeconomic status, community and family support, political issues, war, trauma

Experience of migrationMigrant vs. refugee: Why did they leave? Who was left behind? Who paid for their trip? Means of escape, trauma

Migration History

Degree of lossLoss of immediate family members, relatives, and friends.Material losses: business, careers, properties. Loss of cultural milieu, community, religious, and spiritual support

Work and financial historyOriginal line of work, current occupation, socioeconomic status

Migration History

Medical history Beliefs in herbal medicine, somatic complaints

Family’s concept of illness What do family members think the problem is? Its cause? What do they do for help? What result is expected?

Migration History

Level of acculturationFirst or second generation

Impact on development Level of adjustment, assess developmental tasks