Factors that influence the extent to which traditional ethnic ...

Factors that influence the extent to which traditional ethnic ...

Mental Health Issues in Work with Immigrants and Refugees Georgi Kroupin, MA,LP Center for International Health, St. Paul, MN 1 New Americans: Understanding & Working With Their Mental Health Needs New Americans: Ordinary people under extraordinary stress

2 New Americans Pull immigration Push immigration We mostly deal with the Push immigrants/refugees who experience stress on multiple levels 3 People balancing loss and

gain: living through Opportunities For many basic safety and security For some (seniors, handicapped people, women) more possibilities for independence and self-sufficiency Freedom or communication/information 4 People balancing loss and gain: living through Internal Losses (individual)

Loss of Ease of Communication Loss of Independence and Self-Sufficiency Loss of Security and Stability 5 People balancing loss and gain: living through Environmental losses (individual) Negative Response:

Feeling that life was useless Difficulty finding your niche in the future Acculturation difficulties Hopelessness about the future 6 People balancing loss and gain: living through Opportunities Perspective of gain of material possessions Opportunities for learning Opportunities for cultural development for those who were denied their culture Access to social services for those who need assistance

7 People balancing loss and gain: living through Environmental losses (individual) Loss of Material Possessions Loss of Value of Education and Professional Experience Loss of Roots and Connection to Cultural and Social Traditions Loss of Connection to Family and Friends 8 People balancing loss and

gain: living through Opportunities For those who were denied them, gain of basic civil rights For those who were denied it - may be an opportunity to find their cultural identity 9 People balancing loss and gain: living through Internal Losses (individual) Negative Response:

Feeling powerless, unable to control or even predict future Lack of trust in the system Isolation and Confusion Overuse and Pressure 10 People balancing loss and gain: living through Internal Losses (individual) Loss of Status Loss of Self-Esteem and Personal Identity

11 People balancing loss and gain: living through Internal Losses (individual) Negative Response: Drinking/Drugs/Gambling Family abuse Adultery Mental Health problems Physical illness 12 Irreversible loss and hope for the future

Many refugees have experienced irreversible loss Many also show incredible resilience They may be able to learn how to live with loss and still have hope We need to learn how to tolerate ambiguity and deal with balancing both parts at once 13 People balancing loss and gain: living through

Refugee family with a sick child: Angry father Mother Father Social worker MD Pediatrician Occupational therapist Daughter Son 6 2.5 Daughter 16 Son 12 Nurse

Physical therapist Interpreter 14 From DSM-I to DSM-IIIR: From symbols to signs In Biomedicine diseases are largely biological in nature Disease entities are empirical and universal They are discovered and then described in increasingly full terms

15 From DSM-I to DSM-IIIR: From symbols to signs Pre-DSM period 1840 idiocy and insanity 1880 mania, melancholia, monomania, paresis, dementia, dipsomania and epilepsy 1917 American Medico-psychological Association: uniform statistics for hospitals. Revised in 1934 Revised by the Veterans Administration and the Navy during and after WWII (W. Menninger) 16

From DSM-I to DSM-IIIR: From symbols to signs Mental Hospital Service of the American Psychiatric Association published DSM-I The hallmark of DSM-I is the idea of reaction Symptoms as symbolic statements of underlying problems 17 From DSM-I to DSM-IIIR:

From symbols to signs 1968 DSM-II Stepped away from the idea of psychobiosocial conceptions of mental disorders and dropped the label of reactive Retained the idea that mental illnesses are symbolic expressions of hidden psychological realities 18

From DSM-I to DSM-IIIR: From symbols to signs DSM-III and IIIR: from symbols to symptoms Atheoretical and descriptive Term neurosis dropped as concealing ethiological explanations Intentional move away from psychological understanding of mental disorders A clear step toward the exclusive use of biological

ethiological models Biological model was believed to be more scientific and more mainstream in terms of medicine 19 From DSM-I to DSM-IIIR: From symbols to signs DSM-IIIR: identification of symptoms is transformed an interpretation of symbols of distress into a reading of signs of disease

Away from psychosociocultural context Biological discourse replaces an existential, phenomenological one The afflicted are represented in a purely biological discourse: Schizophrenic replaced by a person with schizophrenia 20 From DSM-I to DSM-IIIR: From symbols to signs Classifications of mental disorders (DSM-IIIR, IV) reflect a momentum in a cultural historic process Psychiatric classifications may be seen

as historical and semantic processes, not things 21 From DSM-I to DSM-IIIR Gaines (1992) In Northern Germanic (Protestant) tradition self is egocentric

It is the locus of action, thought and emotion Self is distinct, autonomous and capable of control and it is a source and center of motivation Social and natural worlds are independent of self and ideally are subject to the actions of self Individual is believed of literally making him or herself Individuation and personal development/growth are central popular and professional issues 22 From DSM-I to DSM-IIIR Gaines (1992) Centrality of notion of self-control in the Germanic tradition (and DSM III+)

Ideal self is the one of self-mastery Out-of-control states are seen as pathological Treatment is designed to assist regaining the ideal of control 23 From DSM-I to DSM-IIIR Gaines (1992) The notion of self as responsible for (self)

control is a central concept guiding clinical practice Clinicians interpret patients without this (unconscious) motivation as not trying, unconcerned about their condition, not taking care of themselves, not involved in their own treatment (lack of agency) It may result in problematic patient/provider interactions 24 From DSM-I to DSM-IIIR Gaines (1992)

Mediterranean self is sociocentric Self concept incorporates other persons Individual character is partially determined by related others (family, people) Self is dependent on the environment and is not completely under selfs control Self is a dependent social construct, not an independent psychological one 25 New Americans: Building a working relationship Establish

rapport Acknowledge stress and loss Access strengths and opportunities Encourage their initiative 26 Refugee Families balancing challenges and opportunities: adaptation Refugee family with a deaf second wife First wife/mother 55 Husband 65

IP: Second wife 40 MD Son 26 Son 22 Daughter Son 20 18 . Daughter 16 DHH Advocate

Child protection Police Family Therapist 27 Cultural issues in providing care

There are barriers in our work that are related to cultural differences and there are other obstacles that may look as such We need to differentiate between the two 28 Cultural issues in providing care

We often need to accept our cultural incompetence We are more similar than different Being different can be an advantage We can use both similarities and differences to learn, understand, build trust, and help 29 Cultural issues in providing care Refugee family with a sick child: An accident Mother Father

Psychologist Midwife Son 7m.o. Nurse Physical therapist Child Protection Interpreter 30 Balancing incompetence and skill: collaboration Aspects which are frequently cultural

Explanatory models of problems Manifestations of mental health problems Communicating mental health problems Understanding/accessing social and MH services Communication and decision making patterns among family-client/patient-helping professional Cultural acceptability of solutions 31

Balancing incompetence and skill: collaboration Assessment: Most of existing instruments are not translated Issues with construct validity: many Western concepts do not exist in other cultures Issues with other validity: mental health problems are manifested differently in different cultures There are major practical limitations: literacy, educational level, etc. 32 Balancing incompetence and

skill: collaboration Barriers, which masquerade as cultural Communication problems on part of helping professionals Language barrier, poor use of interpreters Frank disagreement of clients and their families with professional recommendations Common histories of trauma, loss, political or war violence 33

Language, Culture and Psychopathology Westermeyer & Janca (1997) Language and Cultural issues in MH Denotation Connotation Equivalence in translated materials Specificity of terms Reporting threshold in relation to symptom severity

34 Language, Culture and Psychopathology Westermeyer & Janca (1997) Translation of mental health assessment instruments Translation by a team of bilingual persons

Back translation by one or more persons not familiar with the original version Analysis of the three versions A pilot study in the target population Reevaluation of the pilot study data 35 Cultural issues in providing care Refugee family with a sick child: An accident Mother Father Psychologist Midwife

Son 7m.o. Nurse Physical therapist Child Protection Interpreter 36 Balancing incompetence and skill: collaboration Issues related to our culture Our cultural push to explain, understand Our cultural push to prepare, be in control Our difficulty to accept irreversible loss

Our guilt reaction Our tendency to trust rules more than feelings 37 Balancing incompetence and skill: collaboration Working with other cultures gives us an opportunity to look at our culture Often we assume that we are normal and they are cultural

Understanding our own culture and working with equally important The fact that our culture represents the system may not mean its normal 38 Balancing incompetence and skill: collaboration What do we do? Try to separate cultural issues from other problems Use professional interpreters whenever possible

Look at yourself and you will find both differences and similarities Use both similarities and differences to learn, understand, connect, develop trust, and help 39 New American Families and Social Systems Refugee family with a dying mother Mother Father MD Nurse

Son 48 Son 42 Son 40 . Patient advocate Nurse Nurse Psychologist Chair of Ethics Committee 40 Clinical strategies

Three most important components of successful cross-cultural care: Rapport Rapport Rapport 41 Clinical strategies Effective ways of establishing rapport: Developing curiosity Deconstructing therapy Working with resistance Accessing non-verbal dimensions of your encounter Accepting and utilizing your cultural

incompetence 42 Applying clinical strategies We can be competent in other dimensions of our encounter to compensate for incompetence in certain dimensions (reality check, metacommunication) 43

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