Cultural Competency and Mental Health (PowerPoint) by Alexis Broker

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									        CULTURAL COMPETENCY &
            MENTAL HEALTH

                             Joan (Nyala) Cooper, Ph.D.

 Charles R. Drew University of Medicine & Science
Adjunct Assistant Professor, Department of Psychiatry & Human Behavior
Consultant, National Minority AIDS Education & Training Center
             Pacific AIDS Education & Training Center

       This session is intended to assist
     participants with cultural competency skill
     building in the area of HIV Mental Health.
     Participants will have the opportunity to:

1.   explore their present level of acceptance of
     cultural competency as an important mediating
     variable in decreasing barriers to the
     receptivity of HIV mental health services;
2.   use cultural dimensions to understanding HIV
     risk and treatment seeking behavior; and
3.   apply principles of cultural competency to case
     studies involving HIV and mental health.

The Bio-psychosocial
  model incorporates the
  three major spheres of
       psychological, and
          social into …
   the context of culture.
                                The Cultural Context

Marilyn Martin,
  psychoanalyst and
  author of Saving Our
  Last Nerve: The Black
  Women's Path to Mental
  Health, speaks on
  depression and how
  mental health is innately
  connected to physical
  health. (Central Texas African
  American Family Support
  Conference – Austin Travis Mental
  Health Mental Retardation Center,
                      HIV AND MENTALHEALTH

John Anderson, Ph.D. (2005) states that a solid working knowledge of mental
   health and substance abuse issues is essential for understanding how to help
   people protect themselves from HIV infection, how to help those who are
   already infected from transmitting the virus to others, and how to reduce
   adverse health consequences among those living with HIV.

He underscores the link between HIV and mental health by citing the results of the
   Eric Bing, M.D., et. Al.(2001) HCSUS study that examined mental health and
   substance abuse in a large, nationally-represented probability sample of adults
   receiving care for HIV in the U.S. Nearly half of the sample screened positive
   for a mental health disorder. The results also indicate the high proportion of
   people receiving HIV-related care who also have mental health and substance
   abuse problems. In addition to their negative impact on quality of life
   (Sherbourne et al; 2000), mental health and substance use disorders have
   been consistently associated with increased HIV risk behavior (Hutton et al;
   2004; Booth et al; 1999) as well as poor access and adherence to anti-
   retroviral treatment for HIV/AIDS (Cook et al; 2002; Tucker et al; 2003).
                 HIV AND MENTAL HEALTH

While Anderson states that mental health and substance use
  disorders are highly treatable, they must first be identified
  and referred to appropriate services. He finds it unfortunate
  that “stigma and lack of knowledge about these disorders
  often prevent this from happening (Cooper et al; 2003;
  Kessler et al; 2001).”
The problem of client under-recognition of mental health
  problems is compounded when HIV providers lack the
  experience to adequately assess mental health needs.
  He states “Primary care providers are not well-equipped to
  diagnose and treat common mental health disorders (Staab
  et al; 2001). Additionally, prevention workers and prevention
  case managers typically receive few guidelines and minimal
  training in the systematic assessment of mental health and
  substance use disorders.”

The role of the front line mental health
  professional treating persons with mental
  illness and HIV/AIDS has become more
  complex as the disease and the treatment for
  it changes.
 Prevention Strategies
 Differential Diagnosis
 Mental Health Treatment
 Psychiatric Rehabilitation
 Community Outreach
 Systems Consultation
 Research
                   MENTAL ILLNESS

Persons with mental illness are often at greater risk for
  HIV infection and progression than the general
  population because of the characteristics of their
  illness. Those with severe, chronic (CMI), or serious
  and persistent mental Illness (SPMI) have increased
  risk due to:
 Periodically Impaired Judgment
 Periodically Impaired Cognitive Functioning
 Misinformation about Condom Use
 Difficulty following Clean Needle Precautions
 The Most Vulnerable of the Homeless
 Poverty and Community Environment
 Inadequate Professional Care
 Alcohol and Other Drug Abuse
    (HOPE Curriculum, APA, 2000)
         HIV COUNSELOR PERSPECTIVES, Vol.13, 2, 2004

     People with HIV and people at highest risk for HIV are
diverse, in terms of everything from race and ethnicity,
gender, and sexual orientation, to age and socioeconomic
     Since HIV counselors must explore particularly
sensitive issues – including sexual activity, substance use,
and disease – it is crucial that counseling be well-grounded
in concepts of cultural competence.
     The issue reviews definitions of cultural competency
and the ways in which cultural competence is consistent
with and builds upon client-centered counseling skills and
a counselor’s willingness to learn from clients.
    Some Issues in “Cultural Competency”
HIV Counselor Perspectives (April, 2004) states that there are two main
   schools of thought about cultural competence. They relate that the first
   suggests that counselors should learn beliefs and norms of the specific
   cultures they are working with and mirror those cultures (Wilson,&
   Miller, 2003; Snowden & Jerrell, 2003). The second suggests that
   culturally competent counselors focus on learning skills such as
   openness and active listening that allow them to uncover an individual
   client’s culture and level of acculturation in the course of the counseling
   sessions (Fullilove, M, 1998; Houston-Hamilton, A., 1998; Jue, S. 1988;
   and HRSA, 2001).

The authors further indicate that recently, researchers have re-examined
  how counselors and practitioners view “culture” and the cultural models
  on which prevention strategies are built. In their examination,
  Airhihenbuwa et al; 2000 and Yoshikawa et al; 2003 look at the models
  and definitions to see how they may perpetuate the perception that
  clients who are different are “outsiders” and how this perception may
  impede efforts to reach those in need of service.

Culture is a set of shared behaviors, ideas and values which
  are symbolic, systematic, cumulative and transmitted from
  generation to generation. (L.A. County, Dept. of Health Services)

“Culture is a particular set of values, norms, attitudes, and
  expectations about the world that shapes the personalities
  of those reared in that culture.” (Marin, 1991)

Cultural Competency has been defined as a “set of academic
  and interpersonal skills that allow individuals to increase
  their understanding and appreciation of cultural
  differences and similarities within, among, and between
   (L.A. County, Dept. of Health Services)

The authors of “Cultural Competence and HIV” state that Marin’s
  definition of culture avoids the problem that others have
  identified: in the HIV prevention field, as in other areas, “culture”
  may refer only to racial and ethnic minority status, even though
  White and heterosexual people, for example, were also raised
  with values, norms, attitudes, and expectations (Wilson, 2003).
They further state that others warn that when only non-European
  peoples are seen as having “culture,” their non-European ways
  are defined as barriers to their progress, subtly linking the ideas
  of “culture” and “barrier” (Houston-Hamilton, 1998; Airhihenbuwa et al, 2003).
They identify a third category of “others” who suggest that culture is
  influenced not only by race or ethnic background but also by
  other demographic factors such as age, socioeconomic or
  immigration status, sexual orientation, and history of oppression
   (Brooks et al, 2003; Diaz, et al, 2000).

                           Primary Dimensions
1.   Age
2.   Ethnicity
3.   Gender
4.   Race
5.   Language
6.    Physical Abilities and Qualities
7.   Sexual /Affectional Orientation
8.   Childhood Experiences and
     Family Factors (Family religion, place of birth and household
     location, family social class, parents occupations, etc.)

                Secondary Dimensions
1.   Education
2.   Geographic Location
3.   Income
4.   Marital Status
5.   Military Experience
6.   Parental Status
7.   Religion
8.   Work Experience
9.   Current Social Class

               Tertiary Dimensions

1. Experiences with Immigration, Exile, etc.

2. Lifestyle

3. Degree of Assimilation
                       STAGES OF CULTURAL COMPETENCY

1. Cultural sensitivity or awareness (being
   conscious of the nuances of other cultures and one’s
   own culture)…leads to

2. Cultural knowledge (understanding cultural
   differences, seeking accurate information about a
   cultural group),…which results in

3. Cultural competency (the fusing of sensitivity and
   knowledge with behaviors that enhance interaction
   among persons from varied cultures)
(Kavanagh & Kennedy, 1992; Torres,1993)

Cultural infusion reflects the extent to which
 ethnic/cultural characteristics, experiences,
 norms, values, behavioral patterns and
 beliefs of a target population, as well as
 relevant historical, environmental, and social
 forces, are incorporated in the design,
 delivery, and evaluation of targeted health
 promotion materials and programs. (Myers, Linda James,

1.    Surface Structure – visual aspects such as
      language, dress, diet, clothing, music, etc.
     (Surface Structure usually increases the receptivity,
      comprehension, or acceptance of messages.)

2.    Deep Structure – values, beliefs, philosophical
      assumptions, etc.
      (Deep Structure conveys salience and determines
      program or message impact.)
     (Myers, Linda James, 2003)
                   BARRIERS TO TRUST

        “Historical racism, sexism, and homophobia, both in society
  and in the medical establishment, build barriers for many people
  seeking to access health care, including HIV testing. In particular,
  there is a legacy of mistrust around the treatment of sexual issues by
  the American medical establishment.”
        - The Tuskegee Study
        - Sterilization without Knowledge or consent

Racism, sexism, and homophobia can have powerful effects on:
        - self-esteem
        - communication style
        - body image
        - feelings of control

  which in turn, can diminish a client’s sense of
             - self-protection,
                 - ability to negotiate
                     - and capacity to employ harm reduction strategies.
Erving Goffman, whose seminal work "provides the theoretical underpinnings for much of
    the literature on stigma and stereotyping" (Health Resources and Services
    Administration, HIV/AIDS Bureau [HRSA/HAB], 2003), defines stigma as "an attribute
    that is deeply discrediting" and reduces the stigmatized individual "from a whole
    and usual person to a tainted, discounted one" (Goffman, 1963, p. 3).

HIV infection fits the profile of a condition that carries a high level of stigmatization ... .
   First, people infected with HIV are often blamed for their condition and many people
    believe HIV could be avoided if individuals made better moral decisions.
   Second, although HIV is treatable, it is nevertheless a progressive, incurable disease.
   Third, HIV transmission is poorly understood by some people in the general population,
    causing them to feel threatened by the mere presence of the disease.
   Finally, although asymptomatic HIV infection can often be concealed, the symptoms of
    HIV-related illness cannot. HIV-related symptoms may be considered repulsive, ugly, and
    disruptive to social interaction ... . (HRSA/HAB, 2003)
The result is the widely documented phenomenon of HIV-related stigma. "HIV-related
    stigma refers to all unfavorable attitudes, beliefs, and policies directed toward
    people perceived to have HIV/AIDS as well as toward their significant others and
    loved ones, close associates, social groups, and communities. Patterns of
    prejudice, which include devaluing, discounting, discrediting, and discriminating
    against these groups of people, play into and strengthen existing social
    inequalities – especially those of gender, sexuality, and race – that are at the root
    of HIV-related stigma" (HRSA/HAB, 2003).

Rate Yourself on a scale of 1 to 5 (1 = low and 5 = high)

DOING: How good are you at:

   Personalizing observations (using "I" not "you" messages)
   Paying attention to your feelings (seeking to understand your
    own reactions better)
   Listening carefully (paying attention to verbal and non-verbal
   Observing attentively (watching the client's repeated
    behaviors to try to understand the meaning of those
   Assuming complexity (recognizing that multiple perspectives
    and outcomes exist)
   Tolerating ambiguity (responding to unpredictable situations
    without getting stressed or cranky)
   Having patience (staying calm, stable and persistent in trying
   Managing personal biases (recognizing that everyone belongs
    to many groups and no one represents a group)
                  SELF-TEST ON CULTURAL COMPETENCE (continued)

BEING: How good are you at:
   Being non-judgmental (stopping the tendency to negatively judge others
    who are different)
   Being flexible (readjusting quickly and effectively to changing situations)
   Being resourceful (responding skillfully and promptly in new, uncertain
   Having a sense of humor (laughing at oneself and with--not at--others;
    finding humor in the irony of life)
   Showing respect (honoring others who are different)
   Displaying empathy (feeling the thoughts, attitudes and experiences of

                   Total score: ____

Scores 70 to 61 = highly competent
Scores 60 to 51 = moderately competent
Scores 50 & below = need more practice

Revised by Dr. Mikel Hogan Garcia. California State University at Fullerton. in
   1990 from materials developed by C. Dodd and F. MontaJzo. Intercultural
   Skills For Multicultural Societies (1987) and G. Ferraro. The Cultural
   Dimension of International Business (1990).

Fullilove, M. 1998; Houston-Hamilton & Day, 1998; and Jue, S, 1988 suggest
    that counselors take an approach that focuses on the client’s experience of
    his or her background and present situation. This encourages practitioners
    to shed the idea that the client whose culture is different from the
    counselor’s is “other” and to challenge any stereotypes or assumptions that
    the counselor may have about this “other” culture. As repeated in the APA
    HOPE Curriculum, Hamilton & Day offer four steps to “working downhill” in
    HIV counseling:
1. Find ways to regularly acknowledge to self and client that each individual
   has both cultural and personal histories and that these are integral to a
   sense of self and a shared world view;
2. Incorporate a full range of sensory information and expressive resources to
   uncover the style and medium that make prevention (and treatment))
   messages most accessible, understandable, and acceptable to the client;
3. Modify (prevention) messages, modes, and materials as new information
   emerges that may make culturally-based concepts clearer to individuals
   with different world views; and
4. Account for cultural dynamics on both sides of the table.
                                            CASE STUDY
[This case study is taken from “Cultural Competence and HIV,” HIV Counselor Perspectives, Vol. 13, 2, April 2004.]
Case Study
At the end of a busy antibody test counseling shift, Gloria, a 37-year-old African American test counselor looks up to see Susan, a 24-year-old
       White woman and a new counselor, leaning against the doorframe and looking uncomfortable. Gloria, an experienced counselor, invites
       Susan in and asks her how her last session went.
        "She was negative, thank God," Susan says. "But, there were a couple things I wanted to check out with you. I feel kind of stupid, since
       we just had that class on cultural competence. Do you have time to give me some feedback?"
       As Susan tells her story, it becomes clear that there were a few snags in Susan's session with Louise, a 65-year old African American
       woman and first-time tester. "Somehow we got sidetracked onto how the AIDS epidemic got started. At first, I felt really good talking about
       that, because I know a lot about it and I thought I could build trust by showing I was knowledgeable. But then it started cutting into our risk
       assessment time and I began to rush through
the assessment questions. The client looked offended and got really quiet, and I was really conscious of being this White woman asking her
       these really personal questions.
        "Finally I just said ,'I'm new at this and I don't feel like I'm doing a good job connecting with you. Can we go back a few steps? Is there a
       way I can be more helpful?”
        Gloria praises Susan's decision to seek consultation. She says that she is familiar with African American clients asking about how AIDS
       began. 'It sounds like you might have felt a little insecure, and here was a chance to show your credibility, but then you got sidetracked.
       How do you think it would have been for you to say, 'A lot of people have asked me that, and there are lots of theories. What have you
       heard? What makes sense to you?'" Susan agrees that this approach could have given her a better window into Louise's world View.
       Gloria continues, "And you're right to think she might be checking out your credibility. This woman lived through Tuskegee. Still,
       remember to move on: everybody has a story, and listening to that story can take us to the next step, but stay focused on the client's risk-
       related needs."
       "Another thing that I noticed was that you said you got rushed doing the risk assessment questions," Gloria observes. "Remember, you
       aren't just a White woman and a stranger: you're young enough to be her daughter. And she has never tested before. She's new to our
       'culture.' Maybe going through the risk assessment abruptly felt intrusive. Sometimes, I introduce the assessment by saying, 'I'd like your
       permission to ask you some personal questions about things like sex and drugs. Your answers are confidential, and I hope we can use
       them to identify some steps that will help you protect your health. “Probably the most important thing you can do with any client is to show
       respect and a willingness to listen."
       Gloria adds, ''It sounds like you already know that, because your gut told you things weren't working out and that you needed to reconnect
       with Louise. What happened when you acknowledged the problem and asked Louise what you could do to connect better?" Susan says
       that Louise became a little tearful as she recounted how a friend from church had lost a son to
AIDS. As Susan eased back into the risk assessment, Louise shared more openly. "She even ended up taking some textured condoms to use
       with her 'special friend. 'I was a little surprised those would catch her eye." Gloria says, "So you were able to recover, and Louise helped
       you see where she needed to go next Remember, our clients don't expect us to know everything about AIDS or about them. Be interested
       and learn all you can in the time that you have." Gloria grins, 'We'll talk about your assumptions about senior citizens and sex next time."

         BE SAFE: Another Model for Cultural Competency

Dr. John McNeil (2004) A panel of multidisciplinary and multi-Diaspora
    healthcare providers developed a model for dealing with minority patients
    infected with HIV. Process steps include: Workshop; Literature search; Model
    development; Focus group feedback.
                         Model Development

   FACTS -
Talking with a Patient Whose Native Language May be
Different from Yours*

Improving communication skills is moving toward cultural competence.
    When an appropriate native speaker is not available, an
    English speaking therapist may have to see the client.
    Patients whose English is limited report that they take many
    cues from the listener's face. They report that a good listener:

     Smiles and looks interested.
     Is patient.
     Is cautious about humor which new English
      speakers may find hard to understand.
     Listens carefully.
            Basic Do's of Communicating with limited-English Speakers

   Make your statements as specific as possible.
    Make your statement in a variety of ways, to multiply the chances of
    getting the thought across.
    Keep pencil and paper handy. Use them to write key information for
    the client.
    Watch for responses that indicate real understanding.
    Use body language to illustrate what your words say.
    Avoid contractions.
    Use the vocabulary that the client has used. They are words s/he
    Ask the client to write down any words that you have trouble
   Give general information before dealing with specific issues.
            Basic Do's of Communicating with limited-English speakers

   Let the patient see your lips as you speak.
   Smile.
   Be aware of your assumptions.
   Don't rush. Be patient.
   Listen carefully.
   Speak a little more slowly than usual, but not more loudly.
   Be careful with your pronunciation.
   Stick to the main points.
   Emphasize key words.
   Avoid jargon.
   Use simple sentence structure.
              Basic Do's of Communicating with limited-English speakers

Other Hints
 Avoid asking whether the patient understands. The person is not
  likely to admit not understanding. Instead, ask the client to repeat
  back to you the information you want the client to remember or act
 A limited-English speaker's native language may not have words for
  "could," "might," or "may."
 To the patient, it may sound demanding to say "should." If the
  statement seems not to fit the situation, use other words to clarify.
*Derived from the County of Los Angeles Commission on Human Relations booklet "How to
   Communicate Better with Clients. Customers and Workers Whose English is Limited,"
   (Developed by Carole Chan).

                            SUMMARY & CLOSING COMMENTS

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