Culturally and Linguistically Responsive Care for Early Psychosis

Dr. Jorge Ramírez García

April 8, 2020 CLR & Psychosis 2

Northwest Mental Health Technology Transfer Center

Our Role

Provide training and technical assistance (TA) in evidence-based practices (EBP) to behavioral health and primary care

providers, and school and social service staff whose work has the potential to improve behavioral health outcomes for

individuals with or at risk of developing serious mental illness in SAMHSA’s Region 10 (Alaska, Idaho, Oregon, and

Washington).

Our Goals

• Heighten awareness, knowledge, and skills of the workforce addressing the needs of individuals with mental illness.

• Accelerate adoption and implementation of mental health-related EBPs across Region 10.

• Foster alliances among culturally diverse mental health providers, policy makers, family members, and clients.

The MHTTC uses affirming language to promote the promises of recovery

by advancing evidence-based and culturally informed practices.

April 8, 2020 CLR & Psychosis 4

Today’s Trainer

• Jorge Ramírez García, PhD; Research and Evaluation Scientist

at Oregon Research Institute and has held Program and

Research Analyst and Health Equity Coordinator positions at

Greater Oregon Behavioral Health

• Focuses on service programming and research to strengthen family and community care of individuals with psychosis

• Currently serves on the Cultural Competence and Continuing

Education Steering Committee and the Health Equity Committee

of the Oregon Health Authority

RESEARCH SUPPORTED BY

National Institute of Mental Health NRSA Training Grant MH14584 (Psychological Research on Schizophrenic Conditions) &

Paso del Norte Health Foundation

Overview (Objectives)

I. Importance of: Psychosis and Culturally

& Linguistically Responsive (C&LR) Care

II. Need for C&LR Care for Psychosis

III. C&LR Care for Psychosis Illustrations

IV. Implications

I. IMPORTANCE of Psychosis and of

Culturally & Linguistically Responsive Care

PSYCHOSIS +Delusions; hallucinations; disorganized thought -Deficits: Impaired functioning

0%

10%

20%

30%

40%

50%

60%

Risk

Probability of Schizophrenia by Heredity

Pop. At-large 1 Parent Schiz. 2 Parents Schiz.

April 8, 2020 CLR & Psychosis 8

Diathesis-Stress Hypothesis

Schizophrenia

“ENVIRONMENTAL STRESS”

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Risk

Probability of Schizophrenia by Heredity

Pop. At-large 1 Parent Schiz. 2 Parents Schiz.

April 8, 2020 CLR & Psychosis 9

Course of Schizophrenia Model

April 8, 2020 CLR & Psychosis 10

Public Health Importance

• High global burden of disease

Early onset leads to many years with

disability (psychosis) due to impact on

functioning

Higher risk of co-occurring illnesses with

high disease burden

• Shorter life span

Culturally and Linguistically

Responsive Care

Services that are….

• Respectful

• Responsive to individual’s

• Cultural beliefs and practices

• Preferred language(s)

• Health Literacy Levels

• Communication needs

• Employed by all individuals/members of organization

• Regardless of size

• At every point of contact

Culturally and Linguistically Appropriate Service standards (CLAS)

WHY C&LR CARE?

“Business” Case “Humanitarian / Justice” Case

• Reduce health disparities

Ethnic minorities and/or low income

More likely sick

Poor access to quality care

• Improving quality of clinical care

• Better equipped to respond to cultural / ethnic “gaps”

• Equitable = > Social / Distributive Justice

Culturally and Linguistically Appropriate Service standards (CLAS)

• Reduce unnecessary costs due to

avoidable health disparities;

treatment errors (e.g., $230 billion

lost between 2003-2006)

• Regulations (integrity of services)

• Accreditation (e.g., NCQA)

Communication

Cultural competence

Patient-Centered care

Linguistic Assistance

CULTURE COUNTS, CULTURE MATTERS

Defining Culture

CLAS (Office of Minority Health)

Integrated pattern of thoughts, communication, actions, customs, beliefs, and/or values.

Characteristics partly based on …

Racial; Ethnic; Religious; Spiritual; Linguistic; Socio-economic; or Geographic groups

Kral, Ramírez García et al. (2011)

Health Disparities / Inequities

Specific subset of differences

• Health status

• Health care utilization

• Health determinants

That are largely:

• Avoidable

• Due to social determinants of health

• Due to ethnic/cultural determinants of health

Cook et al. (2014)

II. Need for CL&R care for

Psychosis

As long as there are:

a) Disparities / Inequities

b) Cultural and Linguistic determinants of

psychosis …

There is the need for Culturally and

Linguistically Responsive Care

Cultural and Linguistic determinants of Psychosis have discernible differences between groups

In overall levels

In the way that they impact health or other health factors

Disparities/Inequities in Psychosis:

Latina/os, & ethnic minorities

+ be diagnosed with Schizophrenia

+ have poor outcomes in occupation & social functioning

+ disengage from treatment

+ drop out prematurely

- Participate in case management

- Engage in treatment

- Be rehospitalized

More

Lik

ely

to

Less lik

ely to

Maura & Weisman de Mamani (2017)

April 8, 2020 CLR & Psychosis 19

Linguistic Case Study: “Tiene Nervios”

View that Psychosis is a case of “Nervios” [Nerves]

• “Nervousness” or “distress”? • Therefore DX= Anxiety or

Psychological distress

• Therefore RX=tranquilizers; relaxation techniques

(Guarnaccia et al., 1992)

April 8, 2020 CLR & Psychosis 20

Language and Proverbs:

Caregiving for psychosis

• “Locos, locos… pero no tragan fuego” [Mentally ill… How come they don’t eat fire]: Attributions

• “Si Dios Quiere [God Willing]” : Coping

Kuipers et al (2010)

April 8, 2020 CLR & Psychosis 21

31%

40%

69%

9%

LIV. FAMILY LIV. ALONE

Liv. Arrangements Post-Discharge

Europ. Am. (White) Hispanic

8%

71%

40% 42%

EMOTIONAL OVERINV. CRITICISM/HOSTILITY

Expressed Emotion Subtypes

Europ. Am. (White) Hispanic

Latinx Family Caregiving Face I:

(Over)involved & Burdened

Ramírez García et al. (2004) López; Ramírez García et al (2009)

April 8, 2020 CLR & Psychosis 22

Latinx Family Caregiving Face I:

(Over)involved & Burdened

• LATINO CAREGIVER DISTRESS

• (MAGAÑA, RAMÍREZ GARCÍA ET AL. 2007)

• 20 Latino adults

• 15 Latino caregivers

•

April 8, 2020 CLR & Psychosis 23

(Over)involvement & Burden:

Protectors (Hypotheses summary)

Lower Levels

Over Inv. &

Burden

Coping Efficacy

Acceptance (detachment)

Dorian, Ramírez García et al. (2008) Ramírez García et al (2009)

April 8, 2020 CLR & Psychosis 24

Latinx Family Caregiving Face II:

Warm, Supportive, & Recovery Allies

(Hypotheses summary)

Warmth;

High

enculturation

Lower

Psychiatric

Relapse

Coping

Efficacy

Caregiver

Instr. Support

to Patient Family

Level

Support

of CG Religious

Leader

support

of CG

Medication

&

Treatment

Usage

Non-

Blaming

Attributions

Marquez & Ramírez García (2013)

CLR & Psychosis 25

Ramírez García et al. (2006)

Dorian, Ramírez García et al. (2008)

(Lopez et al 2004; Aguilera et al. 2010)

III. Culturally & Linguistically

Responsive Care for Psychosis

Illustrations

Linguistic / Acculturation Spectrum

• LEP – Interpretation & Translation + Cultural Adaptation

• English Speaking – Cultural Adapt.

Limited English Proficiency (LEP)

Immigrant; 1st Gen.

2nd and Later Gen.

April 8, 2020 CLR & Psychosis 27

Culturally & Ling. Resp. Care:

Psychosis + Language & Culture

PSYCHOSIS

Cognitive challenges require information to be:

*Simple

*Bite sized

Limited English Proficiency

* Translation

* Interpretation, or

* Bi-Multilingual staff

Culture

Respond to …

* Behavioral / Linguistic Acculturation

* Values / Attitudes

* Identity

April 8, 2020 CLR & Psychosis 28

Quality

Written Translation

Oral Interpretation

Linguistically Responsive Care

April 8, 2020 CLR & Psychosis 29

Cultural Responsiveness (CR):

Frontline Workers

SKILLS

AWARE:

SELF

CR

AWARE:

FELLOW

AWARENESS OF

• One self

• Fellow human beings (“others”)

SKILLS: • Focused on interaction

(“process”)

• Dynamic; iterative

• Shifting cultural lenses

(Lopez)

• Scientific Mindedness (Sue)

April 8, 2020 CLR & Psychosis 30

Shifting Cultural Lenses & Psychosis

Engagement &

Assessment

Theory Intervention

• Engagement: Establishing a working relationship

• Definition of problem • Helper model

• Theory=Explanatory model of • Person’s functioning • How therapy works

• Intervention = Treatment methods

• Procedures to facilitate behavior change

• Openness to adapt the intervention method to patients’ expectations

April 8, 2020 CLR & Psychosis 31

Lopez et al. 2002

TOOLS & EXAMPLES

(Workforce focused)

CULTURAL RESPONSIVENESS

DOMAIN(S)

Cultural Formulation Interview

(DSM-V; Lewis-Fernandez)

Skills; Assessment; Engagement

Social & Cultural Assessment of

Hispanic Immigrants

(Guarnaccia, 1996)

Assessment: (a) Language; (b) Family

Structure; ( c ) Social supports; (d)

Migration experience; ( e ) Religious

beliefs & Practices; (f) Health Care

utilization

Culturally and Linguistically

Appropriate Services standards

https://thinkculturalhealth.hhs.gov

Targets entire tripartite model; Includes

how to elicit narration of problem.

Check your regional/state

resources

April 8, 2020 CLR & Psychosis 32

Cultural Responsiveness of

Programs

APPROACHES TYPE

Goal:

Optimize Cultural and Linguistic

Responsiveness

Culturally Resp. Program

ADAPT

(Existing Program)

MODIFY:

Surface Structure (Characteristics)

MODIFY:

Deep Structure

(Content “targets”)

DEVELOP

(New Program)

Cultural / Linguistic Elements key foundations

April 8, 2020 CLR & Psychosis 33

Culturally Responsive Programs

& Targets

Culturally Adapted Program examples

Social skills training for Latinos (Liberman &

Kopelowicz, 2009; Kopelowicz, 1998)

Multi-Family Group (Kopelowicz et al., 2012;

2015)

Culturally-Specific (Developed) Program

Examples

Culturally Informed Family Intervention

(Weisman et al., 2014)

Psychosis Health Literacy: Community outreach

– La Clave [The Clue] (Lopez et al. 2018)

Cultural Targets (Maura & Weisman de Mamani, 2017)

Family Involvement

Religious/Spiritual Values

Community Engagement

Stigma

Trust / Confidence in mental health systems

April 8, 2020 CLR & Psychosis 34

Shifting Cultural Lens – Expanded

(La Clave)

COMMUNITY OUTREACH:

+ Increase knowledge of psychosis

+ Efficacy beliefs to identify psychosis

+ Professional help-seeking

• Discern attributions to psychosis

(Lopez et al. 2009)

III. IMPLICATIONS FOR PRACTICE &

RESEARCH

37

(Compton et al. 2011)

Lighthouse: Quality & Rigor

Taxed Workforce

Admin burden

DEI & Other

Trainings

Complexity of Culture

• Optimize value of training & programming (avoid extremes)

• Increase rigor to produce results and garner buy-in from all stakeholders

Integrate Ethnic/Cultural & Social Determinants

of Psychosis (health)

Integrate Ethnic and Social Determinants of Health in

Assessments, Intervention & Research

Braveman et al. (2011)

April 8, 2020 CLR & Psychosis 39

Ethnic & SDOH

Level 1: Individuals

• Social-Cognitive Interpretations

• Health (& Psychosis)

• Identity

• Stress appraisals & Coping

• Norms & Values

• Cultural change

Ramírez Garcia (2019)

April 8, 2020 CLR & Psychosis 40

Ethnic & SDOH

(Psychosis) –

Levels 2 to 4

Social Structures

Built Environment

Relationships & Community

• Education / health literacy

• Vocation/ Occupation

• Living arrangements/Housing

• Segregation / criminalization

• Family / Close relationships

• Social networks

Ramírez Garcia (2019)

Use CLAS and Dissemination & Implementation

Science to promote C&LR Care

Cultural & Linguistic Appropriate Standards

Dissemin. & Implementation Science

Examples of Value

• Importance of Organizational Leadership

• Defining Units of analyses

Chambers & Norton (2016)

Culturally and Linguistically Responsive Care for Early

Psychosis

Questions and Final Remarks

Get in Touch! Visit us online:

www.mhttcnetwork.org/northwest

Find out about:

• Upcoming trainings

• New online trainings

• Resources and Research Updates

Email us:

northwest@mhttcnetwork.org

Follow us on social media:

@NorthwestMHTTC

Thank You!