Reinventing Ourselves as Mental Health Clinicians When Working with Refugee and Immigrant...
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Transcript of Reinventing Ourselves as Mental Health Clinicians When Working with Refugee and Immigrant...
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: [email protected]
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