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Presenters: Peter J. Guarnaccia, Ph.D. - Rutgers University Igda Martinez, Psy.D. – Albert Einstein College of Medicine Henry Acosta, MA, MSW, LSW – National.

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Presentation on theme: "Presenters: Peter J. Guarnaccia, Ph.D. - Rutgers University Igda Martinez, Psy.D. – Albert Einstein College of Medicine Henry Acosta, MA, MSW, LSW – National."— Presentation transcript:

1 Presenters: Peter J. Guarnaccia, Ph.D. - Rutgers University Igda Martinez, Psy.D. – Albert Einstein College of Medicine Henry Acosta, MA, MSW, LSW – National Resource Center for Hispanic Mental Health National Resource Center for Hispanic Mental Health® Changing Minds, Advancing Knowledge, Transforming Lives Training Held on May 5, 2012 on behalf of the agencys project: Partners for Culturally Competent Behavioral Health Service Delivery to Hispanics 1

2 Acknowledgement Funding for Partners for Culturally Competent Behavioral Health Service Delivery to Hispanics was made possible through a grant from the Bristol-Myers Squibb Foundation. BMSF had no control over the contents of todays training or any other program development or intervention activities 2

3 Henry Acosta, MA, MSW, LSW National Resource Center for Hispanic Mental Health 3

4 10:00 am-10:15 amWelcome, Overview & Introductions: Henry 10:15 am-10:45 amAssessing Diversity among Latinos: Peter 10:45 am – 11:00amBreak 11:00 am-12:30 pmLatino Mental Health: Focus on Depression and Its Treatment: Igda 12:30 pm-1:30 pmLunch 4

5 1:30 pm-2:30 pmDSMIV, Cultural Formulation and Latinos: Peter 2:30 pm – 2:45 pmBreak 2:45 pm-3:30 pmUsing Genograms to Elicit Cultural & Family Issues: Igda 3:30 pm-3:45 pmSocial & Cultural Assessment of Hispanics: Peter 3:45 pm-4:00 pmEvaluation & Wrap-Up 5

6 Peter J. Guarnaccia, Ph.D. Rutgers, The State University of New Jersey 6

7 7

8 8

9 One of the most popular debates and one of the least likely to be solved Hispanic adopted by U.S. Census in 1970 Seen as an imposed term by U.S. government More identified with Spanish origins Latino refers to Spanish, Indian & African origins of people from the Americas 9

10 Source : U.S. Census,

11 Principal Investigators Margarita Alegria, Harvard Medical School David Takeuchi, University of Washington Funding: National Institute of Mental Health, SAMHSA/CMHS and OBSSR Latino Sample: Nationally representative household sample: adults 18 and older 11

12 75.5% response rate Instrument fully translated and adapted into Spanish Administered by trained bilingual/bicultural lay interviewers Analyses performed with sample weights to account for complex sample design 12

13 Cubans are significantly older than the other Latino groups 13

14 Mexicans and Cubans include slightly more males than the other Latino groups 14

15 Mexicans have less education than the other Latino groups 15

16 Mexicans have significantly lower incomes than the other Latino groups 16

17 Puerto Ricans are all citizens. About 60% of the other 3 groups are citizens. 17

18 About 85% of Cuban respondents were born in Cuba. Over half of Puerto Ricans were born on the mainland. 18

19 More likely that both parents born In US than 1 parent; Cubans least likely to have US born parents 19

20 Puerto Ricans have spent more of their life on the U.S. mainland 20

21 Cubans were the only group where a large majority expressed a desire to move to the US 21

22 Cubans were more likely to have carefully planned their move to the US 22

23 % Very Important Reason for Move Puerto Rican CubanMexicanOther Latinos p Employment Join Family Improve Future for Children Political Situation Seek Medical Attention Seek Education Family Problems

24 For Cubans visiting relatives in their home country was very difficult. For Puerto Ricans it was easy. 24

25 Cubans were most likely to prefer the interview in Spanish, followed by Mexicans. Puerto Ricans more often preferred English. The bilingual group was small and of similar proportions across the groups. 25

26 There was a trend for Cubans to prefer Spanish and Puerto Ricans English in general use. But there was more expressed bilingualism for this question. 26

27 Overwhelmingly, everyone spoke Spanish as children. 27

28 Puerto Ricans are most English proficient; Cubans are least. 28

29 Cubans are most Spanish proficient, with the other groups being similar. 29

30 Everyone identifies closely with their Latino group. 30

31 Relatively few think it is important to marry within their Latino group. 31

32 Puerto Ricans experienced significantly lower acculturative distress; Mexicans reported the highest levels of acculturative distress. 32

33 Puerto Ricans reported significantly higher levels of Family Cultural Conflict than Cubans or Mexicans 33

34 Puerto Ricans and Other Latinos report a significant decline. Cubans on average report a slight increase in social position in the US. 34

35 There are major differences among the 4 groups in terms of their migration experiences Puerto Ricans are migrants; the other groups are immigrants Cubans reported coming overwhelmingly for political reasons; the reasons for the other groups were more diverse The reception by U.S. society of the four groups was different depending on how and why they came Acculturation processes begin in peoples home countries given the impact of globalization The 4 groups are also different in terms of the historical relationships between their home countries and the U.S. 35

36 The majority of Puerto Ricans, Mexicans and other Latinos (compared to one-third of Cubans) have spent more than 70% of their life on the mainland This has led to the emergence of new cultural mosaics which include the Nuyorican culture of Puerto Ricans in NYC and the Chicano and Hispano cultures of Mexicans in the southwest 36

37 There is considerable diversity among the 4 Latino groups in language preference and use. Language use looks different depending on the context you ask about For example, the distribution of language use is quite different for language of interview compared to language of thought 37

38 Differences in social capital and in reception by U.S. society result in significant differences among the groups in social status Cubans are the only group that report a status increase Puerto Ricans and Other Latinos report a large status decline, while Mexicans report a small status decline The reasons for these differences are not currently well understood 38

39 Cubans reflect one end of the continuum where they strongly maintain Spanish language in all contexts By transforming Miami, they were able to succeed without giving up important aspects of their culture Other Latino groups are more diverse in their cultural experience, more dispersed geographically, and have more diversity in social capital They have not come to economically and politically dominate one area leading to very different acculturation experiences 39

40 Igda E. Martinez, Psy.D. Albert Einstein College of Medicine 40

41 Es como perder su techo, perder todo, es como cuando uno ha pasado por un terremoto y perdió todo … es como una acumulación de perdidas Its like losing the roof over your head, losing everything, its as if one had gone through an earthquake and lost everything … its an accumulation of losses 41

42 Richer understanding of Latinos conceptions of depression Fuller understandings of Latinos attitudes towards, concerns about, and expectations for treatment Identify barriers to care from the perspective of community members 42

43 Based on four different projects in New Jersey and New York to examine: diverse Latinos conceptions of mental health, treatment and barriers to care elderly Latinos understandings of depression and reactions to standard depression measures community concerns about health and mental health and needed services recognition of depression and attitudes towards care 43

44 94 participants in 12 different focus groups throughout New Jersey and New York City Diverse group of Latinos in terms of country of origin, time in U.S., age, gender, education All of the groups were held in Spanish All groups led by Peter Guarnaccia Majority of the groups facilitated by Igda Martinez 44

45 Social relationships and supports are key to mental health Mental health was defined as being able to function in and contribute to society It is being able to live una vida tranquila Being in control of ones emotions and not being aggressive Not abusing alcohol or drugs 45

46 Para mi una buena vida sería llevar una vida de tranquilidad, sentirse con un poco de salud, que es lo principal, y... sentirse para mi bienestar con su familia unida y vivir tranquilo. A good life would be living a tranquil life, being in good health, thats the most important … to feel a sense of well-being about my familys unity and to live peacefully 46

47 Depression is widely recognized among Latinos as a mental health problem Recognize both emotional and somatic aspects of depression Depression is seen as the result of social stressors and losses: – death of a family member, isolation/loneliness, loss of a job and financial stresses, events of September 11 th Depression often connected to diabetes (and other conditions such as high blood pressure) 47

48 Cuando una persona está triste, está nostálgica, se pone a llorar facilmente, está muy cansada y no sabe por que, no tiene ganas de hacer nada. Uno no tiene amigos, no tiene familia, ni nada. Le hace falta más la familia. When a person is sad, is nostalgic, s/he cries easily, feels very tired and doesnt know why, s/he has no desire to do anything. One doesnt have friends, doesnt have family or anything. When you feel like this, you miss your family even more. 48

49 [Los hombres] se deprimen, ellos buscan el alcohol para escaparse y no deprimirse. Tienen que hacerse a cargo de la familia acá y tambien mandarle dinero a la familia allá. Conseguir trabajo aquí es difícil. Men get depressed. They seek out alcohol to escape and not deal with their depression. They are responsible for their family here and also have to send money to their family there, and finding work here is difficult. 49

50 Nunca la cojí la consejeria porque yo dije, pero si ellos me la están ofreciendo y yo fui y yo me presenté. Pero me dijeron, no, el seguro de su esposo no cubre eso. Necesita $250 de down. I never received the counseling. They were offering me the counseling and I went and presented myself. But then they said, no, your husbands insurance doesnt cover this, we need a $250 down payment. 50

51 [Nosotros] inmigramos, y nos encontramos con muchas barreras como el idioma, no tenemos papeles, no tenemos información de muchas cosas, no sabemos cuales son nuestros derechos… la vida aquí es muy difícil. Estamos muy aisladas aquí. We immigrate here and find ourselves with many barriers: such as language; we dont have papers; we dont have information about many things; we dont know what our rights are … Life here is very difficult. We are very isolated here. 51

52 En la cultura Hispana, piensan que ir a ver a un psicólogo es cosa de locos. Es la parte de ignorancia, saber entender y saber donde pedir ayuda. In the Hispanic culture, we think that going to a psychologist is only for people who are really crazy. Its due in part to ignorance, not being able to understand depression, and not knowing where to go for help. 52

53 Seek help from primary care providers because are not aware of mental health as a specialty service Language barriers and cultural issues in understanding American style of mental health treatment Need to be accessible, to build trust [confianza], and to treat people with respect [respeto] 53

54 Yo he ido a unos cuantos psicoterapias... yo fui a uno que se sentaba y me decía habla y parecía que le estaba hablando a una pared. Pero el de ahora habla, da sus opiniones, se ve que está interesado en conocerme a mi. El trata de obtener mi confianza y así me hace sentir mas cómoda... Ive gone to several psychotherapists… I went to one who sat down and said talk and it felt like I was talking to a wall. But the one I see now talks, gives his opinions, I can tell that he is interested in getting to know me. He tries to obtain my trust and thus makes me feel more comfortable... 54

55 Belief that depression is a consequence of difficult life circumstances, not an illness Feeling of trying to deal with problems on ones own [hay que ponerse de su parte] Medications are only for people who are severely mentally ill 55

56 Tendency to seek out talking cure first Need to unburden oneself [desahogarse] Medicine seen as a last resort and a temporary solution Fear of side effects and addictive potential of psychiatric medications 56

57 Fear of addiction is very strong Use models of sleeping pills and coffee to understand medicines Over time people need more and more to have an effect, and it is difficult to stop When a doctor directly explains the difference and that the medicine can be stopped, people are much more likely to accept the medicines 57

58 Nosotros los Hispanos, nos hemos acostumbrado en los remedios caseros … la medicina en realidad no es muy receptiva. We Hispanos have become accustomed to using home remedies … in reality, medications are not very well received by the Hispanic community. 58

59 Therapists need to be sensitive to cultural expressions of depression (ie, somatization, coraje, and various forms of nervios) Therapists need to orient Latino patients to the process of mental health treatment Therapists need to directly explain medications and address concerns about addiction 59

60 Programs to help new Latino immigrants to adjust to life in the U.S. Programs to reduce the stigma of mental illness and mental health care More public information in Spanish about where to get mental health help and how to access care 60

61 ¿Que hace uno cuando hay un problema? Se preocupa. Pero para resolver hay que quitarle el pre y ocuparse What do you do when you have a problem? You worry. But to resolve a problem, you have to take off the pre and take care of it! 61

62 Immigrant Latinos experience lower rates of depression than their U.S.-born compatriots and than non-Hispanic Whites – However, Latinos are more likely to endorse depressive symptoms on item checklists Latinos are less likely to seek mental health services when they are depressed compared to Whites (Vega et al, 1998) Immigrant Latinos have lower rates of service utilization compared to US born Latinos (Alegria et al, 2004) 62

63 Minority group members have additional concerns when entering treatment settings (Atdjian & Vega, 2005 ) Latinos are more likely than whites to have negative beliefs about antidepressants (Cooper et al, 2003; Miranda & Cooper, 2004) Latinos may not initially seek treatment for depression because they see it as a natural reaction to lifes problems, not as an illness – Latinos show a preference for psychotherapy over medications (Martinez & Guarnaccia, 2007) – Fear of addiction and stigma attached to taking medications – Cultural value placed on desahogo, or unburdening oneself 63

64 Multiphase study to adapt Motivational Interviewing (MI) techniques to increase adherence to antidepressants among Latinos Phase I: Focus Groups & MI Adaptation Phase II: Pilot test of MI Adaptation Phase III: Randomized Control Trial 64

65 What cultural values influence peoples decisions to take medications or not? What do participants know about antidepressant medications and what fears do they have about this treatment? Are participants able to accept the treatment recommendations of their providers? What influences their willingness to accept treatment? 65

66 Tendency to value family relationships over other social relationships – Includes concepts such as respeto (respect)to refer the hierarchical nature of family dynamics (Garcia-Preto, 2005). A manifestation of the collectivist nature of Latinos – Benefits, status, and general well-being of the group take precedence over those of an individual. Dynamic concept – Represents family unity, respect and responsibility – Creates both positive and negative pressures – Can lead to covering up severity of depressive symptoms in order to protect family members 66

67 Instances in which family was mentioned Not necessarily describing the overall value of familismo. Tendency to focus more on instrumental support Important in the individuals conceptualization of depression or its treatment Directly challenged or influenced clients understanding or behavior. 67

68 Multiphase study Results presented are data from Phase I 6 focus groups, 30 participants Completed between April – August 2006 Average group size = 5 participants Audio-taped and transcribed Analyzed using ATLAS.ti 68

69 80% female Age range Average: 47yrs Time in U.S yrs Average: 18 yrs Time w MDD <1-30 yrs Average: 11 yrs Time on meds <1-24 yrs Average: 9 yrs 50% PR; 23% DR; 17% MX; 10% other 73% completed HS or more 80% read Spanish Well/fairly well 83% do not speak English 73% speak mostly Spanish with family 63% speak mostly Spanish with friends 69

70 Familismo 50 instances were coded Brought up by 73% of the participants (n=22) Family Influence 84 instances were coded Mentioned by 80% of participants (n=24) 70

71 Queremos mucho a los hijos, los papas, todo, como queremos estar siempre unidos…y todavía se casan y uno quiere los nietos y tol mundo…que este reunido en la familia, somos la familia muy unidas. We care for our children, our parents, everyone, very much; we want to be always united… and even when they get married …one would like ones grandchildren and everyone … to join together in the family, we are very united families. 71

72 Otra cosa que no me gusta de aquí…uno no le puede decir nada a los hijos…hacen lo que le da la gana…aquí no hay niños y los hijos son los padres, como quien dice. Ellos no obedecen, ni na. En nuestros países no. Todavía yo vieja obedecía a mi mama y mi papa. Another thing that I dont like about here…one cant say anything to ones children…they do whatever they want…here there is no youth and the children are the parents, in a way. They dont obey or nothin. In our countries, no. Even in my old age I obeyed my mom and my dad. 72

73 A mi lo que me motivo fue mi familia, porque mi familia ahorita no esta conmigo pero ya va a venir mi hija y mi esposa. Entonces yo, yo, mi problema fue que yo no quería hablar con nadie y yo no le tenia confianza a nadie y fue lo que me motivo a tomarla, el querer estar bien para cuando viniera mi hija y mi familia. What motivated me was my family, because my family right now is not with me but soon my daughter and my wife will come. So then I, I, my problem was that I did not want to talk with anyone and I did not trust anyone, and what motivated me to take [the antidepressants], was wanting to be well for when my wife and my family came. 73

74 …el ver que eran ellos los que ya me lo estaban bañando o dando de comer porque yo pasaba llorando, tirada en la cama, eso fue lo que me hizo a mi…claro, que era yo la que tenía que hacerme responsable de mi hijo y dejar que mis otros dos hijos tengan su niñez. …to see that it was they who were already bathing him and feeding him because I spent my time crying, lying in bed, that was what made me… Of course, it was I who needed to make myself responsible for my son and let my two other children have their childhood. 74

75 Yo no comparto con mi familia mis problemas porque no quiero molestarlos …cuando ellos me preguntan que como estoy yo les digo que bien o que a veces me siento triste para no preocuparlos y ya todo lo que siento lo cuento a la doctora I do not share my problems with my family because I do not want to bother them… when they ask me how I am doing I tell them that I am fine or that sometimes I feel sad so that I do not worry them and then everything that I feel I tell the doctor. 75

76 … es preferible uno hablar esas cosas con un particular que con la misma familia. Con mis hijos yo no hablo nada de lo que siento...pero fíjate, yo a veces me siento que seria bueno uno poder hablar con los hijos o con la familia y compartir el dolor que uno siente, pero al fin y al cabo lo que salen son problemas, mas problemas. … it is preferable for one to speak about those things with someone in particular than with your own family. With my children I do not say anything about what I feel...but you know I sometimes feel it would be good to be able to speak with one's kids or with the family and share the pain that one feels, but in the end what you get are problems, more problems. 76

77 Treatment Supportive family influence 60% of participants mentioned (n=18) Help access care Providing support and reminders to take medications Help to obtain medications Treatment Discouraging family influence 30% of participants mentioned (n=9) Expressed disagreement with the concept of depression as an illness or the need for medications as treatment. 77

78 Ella sale a, trata de buscar el dinero para comprar la pastilla. Si ve que me falta, me la busca. Cuando la dejo en la farmacia, ella va y me la recoge. Si por caso, no tengo tiempo, ella trata de ser pendiente. Me dice, ¿Tienes las pastillas contigo? She goes out to, she tries to find the money to buy the pill. If she sees that I am short, she looks for it. When I leave it at the pharmacy, she will go and pick it up for me. If for any reason I dont have time, she always tries to pay attention, she says to me, Do you have the pills with you? 78

79 Y mi hermana fue la que me llevo y yo estaba como muy, padonde quiera que ella me tiraba yo me iba… Ella era la que me decía a mi, Gloria, te tienes que tomar este medicamento. Y yo decía, ¿Pa que es eso? Entonces dice, Para curarte, para que estés bien como antes. And my sister was the one who took me and I was very, where ever she took me I would go…She was the one who would say to me, Gloria, you have to take this medication. I would say, Whats that for?and then shed say, To cure you, so you can be well, like before. 79

80 …mis padres me enseñaron …que podíamos bregar con los problemas sin necesidad de medicamentos. Y a la vez que uno empezó con medicación …yo me sentí como si hubiera sido como de otro planeta vamos a decir. Era algo que estaba fuera de mis manos. …my parents taught me that …we could deal with problems without medication. And the minute that I started with the medication …I felt as if I was from another planet, lets say. It was something that was out of my hands. 80

81 A veces mi mama me dice, Yo tantos problemas que he tenido y nunca he tenido que ir a un psiquiatra. ¿En que fallaste tú? ¿Qué tu hiciste? Y yo bueno, Cada cual es un mundo diferente, le dije yo. A lo mejor tú pudiste con tus problemas pero yo con los míos no. Sometimes my mom says to me, Me with all the problems that Ive had and Ive never had to go to a psychiatrist. What did you fail in? What did you do?And I well, Everyone is different, I tell her, Maybe you could deal with your problems but I cant with mine. 81

82 Families are important Familismo served in some cases as a motivating factor to seek treatment, and in some cases as a trigger for depression. A new issue arose within the value of familismo: the idea of protecting the family from self Families influenced the ways FG participants understood their symptoms and viewed their treatment. 82

83 What cultural values influence peoples decisions to take medications or not? Familismo Religion Poner de su parte (Do ones part) Trabajar/luchar/aprovechar (Work/Struggle/Take Advantage) 83

84 Clinicians need to be culturally sensitive – It is not always wise to include or exclude family members in treatment – Should listen to the patients own experience of family relationships and decide together – If family is included, focus should be on psychoeducation Patients should be encouraged to take an active role in treatment planning – Patients should be empowered to negotiate with clinician and decide their familys role in their own treatment. 84

85 Peter J. Guarnaccia, Ph.D. Rutgers, The State University of New Jersey 85

86 Cultural Identity of the Client Cultural Explanations of the Clients Illness Cultural Factors Related to the Psycho-Social Environment and Levels of Functioning Cultural Elements of the Relationship between the Provider and Client Overall Cultural Formulation Outline for Cultural Formulation, DSM-IV 86

87 Cultural Explanations of the Clients Illness Predominant illness idioms Relation of client's signs and symptoms to cultural norms Local illness categories Perceived causes used to explain illness Current preferences and past experiences of help seeking 87

88 An idiom of distress particularly prominent among Latinos from the Caribbean, but recognized among many Hispanic groups Commonly reported symptoms include: screaming uncontrollably, attacks of crying, trembling, heat in the chest rising into the head, and becoming verbally or physically aggressive Dissociative experiences, seizure like or fainting episodes and suicidal gestures are prominent in some ataques but absent from others Glossary of Culture-Bound Syndromes, DSM-IV 88

89 A general feature of an ataque de nervios is a sense of being out of control Ataques de nervios frequently occur as a direct result of a stressful event relating to the family, such as news of a death of a close kin or a separation/ divorce from a spouse After the ataque de nervios, people often experience amnesia of what occurred. However, they otherwise rapidly return to their usual level of functioning. 89

90 While descriptions of ataques de nervios most closely fit with panic episodes, factors that distinguish them from panic include: association of most ataques with a precipitating event frequent absence of the hallmark symptom of acute fear or apprehension Ataques de nervios span the range from: normal expressions of distress not associated with psychiatric disorder to expressions of distress associated with anxiety, depression, dissociation, or somatoform disorders 90

91 Guarnaccia, et al., 1993, JNMD 91

92 Ataques distinct from PD Provoked Crescendo > 10 minutes Followed by relief Common to Ataques and PD Recurrence Symptoms during episode Fear during episode Sequelae 92

93 Community Sample (n = 1891) Diagnoses Absence of AdN (n=1723) Presence of AdN (n=168) 2 Any Depression33 (2.3)16 (15.2)8.11** Any Anxiety87 (5.4)38 (22.1)17.88*** Any Disruptive171 (9.7)39 (24.8)12.09*** Any Diagnosis243 (14.0)62 (40.9)24.43*** Any Impairment196 (10.5)55 (39.6)19.20*** Guarnaccia, et al., 2005, JAACAP 93

94 Clinical Sample (n = 757) Diagnoses Absence of AdN (n=563) Presence of AdN (n=194) 2 Any Depression39 (7.0)57 (30.2)45.66*** Any Anxiety83 (14.6)72 (37.7)35.53*** Any Disruptive190 (33.4)98 (50.7)18.50*** Any Diagnosis251 (44.7)125 (65.4)27.75*** Any Impairment245 (44.1)118 (62.4)21.55*** Guarnaccia, et al., 2005, JAACAP 94

95 *** Guarnaccia, et al.,

96 Social and psychiatric vulnerability Relation to panic disorder Relation to depression and suicidal ideation & attempts Relation to dissociation Relation to trauma 96

97 Folk illness prevalent among Latinos in the U.S. and among people in Mexico, Central America and South America Susto results from a frightening event causing the soul to leave the body and resulting in unhappiness and sickness Symptoms may appear anywhere from days to years after the fright is experienced and may result in death. Glossary of Culture-Bound Syndromes, DSM-IV 97

98 The core symptoms include: lack of appetite or appetite gain; sleeping too much or too little; troubled sleep or dreams; feeling sad; lack of motivation to do anything or go anywhere; feelings of low self worth or dirtiness Diagnosis of susto is often confirmed by family, friends and especially by a traditional healer, who will help the sufferer to identify the source of the fright Sufferers of susto also experience significant strains in key social roles. 98

99 Treatment for susto often occurs simultaneously from biomedical providers and traditional healers A ritual healing is performed to call the soul back to the body and to "cleanse" the person to restore bodily and spiritual balance An interpersonal susto characterized by feelings of loss, abandonment and not being loved by family with accompanying symptoms of sadness, poor self image, and suicidal ideation seems to be closely related to major depression 99

100 Mexican Americans in Texas, Mexicans in Guadalajara & mestizos in Guatemala all recognize susto as an illness Puerto Ricans do not Fright, but not necessarily soul loss, a key symptom Core symptoms: agitation, crying, nervousness, trembling, fear of unfamiliar places, sleep disturbances Serious illness that could cause diabetes and lead to death Weller, et al., 2002, CMP 100

101 Women with susto (cibih in Zapotec) more likely to meet CES-D criteria for depression than those without (72% vs. 24%; N=40) Types of susto InterpersonalDepression Feelings of loss, abandonment by family, sadness, poor self image, suicidal ideation Traumatic event PTSD Somatic symptomsSomatoform Health care from several practitioners Taub,

102 69% reported susto and 65% nervios (N=400) Higher depression scores (Zung scale) for both susto and nervios sufferers Susto: 42 points vs. 38 (p<.04) Nervios: 44 points vs. 34 (p<.001) Those with susto and nervios higher depression scores Those with nervios more likely to be diagnosed as depressed compared to those with susto Weller, et al.,

103 Vulnerability to distress Relation to fright, anxiety and trauma Relation to depression Relation to somatization Link to diabetes Greater risk of mortality 103

104 Source: Communicating Effectively Through an Interpreter. Cross-Cultural Health Care Program, Seattle, WA, 1998.© 104

105 Incorporate a mixed anxiety-depression diagnosis Included in ICD-10 Fits with a number of cultural syndromes Common presentation in primary care Refine and expand Outline for Cultural Formulation Update Glossary of Culture-Bound Syndromes Link syndromes to specific disorder chapters 105

106 Anxiety Depression Dissociation Cultural Syndrome Somatization 106

107 107

108 Rural migrant from Puerto Rico 13 years in U.S. Circular migrant Predominantly Spanish-speaking Poor English fluency Lived in Puerto Rican neighborhood Limited contact with broader society 108

109 Nervios and Ataque de Nervios Fits of anxiety and rage, followed by impulsive suicidality Distressing, but culturally specific, dissociative symptoms (hearing voices, seeing shadows) Children saw as difficult, overwhelming Nerves altered by unresolved family conflicts First saw internist, then accepted family therapy and medical supervision of Latino psychiatrist 109

110 Key stressor – estrangement from children First husband abusive, second murdered Daughter had drug problems and lost her children Precarious social supports 110

111 Treatment prior to Latino clinic hindered by lack of cultural assessment of symptoms Latino clinic provided more intensive assessment Focus on character pathology 111

112 Corrected psychotic label resulting from dissociative symptoms and stopped antipsychotic medications Focused on resolving family conflicts with children through family therapy Diagnosis refocused on Borderline Personality Disorder Recurrent dysphoria, but did not meet criteria for Dysthymia 112

113 Igda E. Martinez, Psy.D. Albert Einstein College of Medicine 113

114 Sociocultural, sociopolitical, & socioeconomic factors Finances Cultural Heritage Belief systems, religion, spiritual beliefs Language skills and acculturation of family members Connections to community Migration history 114

115 Are there sociocultural factors (ethnicity, race, social class, legal status, employment potential, education level) that are impacting familys current functioning? Any past suffering/conflicts with family members due to past political history? Where does family fit in the community? 115

116 Pressures from family – jealousy, resentment, pressure to help other family members Shame or conflict due to loss of status Upper class in country of origin Lower class in US Struggling to meet ongoing needs 116

117 Culture/ethnic background of family members Experiences with racism How are they received in their local communities? Are belief systems accepted/encouraged? 117

118 What primary beliefs organize the family? What is the history of the familys beliefs, what have been the changes, if any? Reactions to changes in the family? Differences within the community? 118

119 What languages are spoken in home? Among adults? Children? Power imbalances? How much of heritage is retained? How are those decisions made? 119

120 How do family members maintain friendships? How accessible are social support networks? Friends, family, school, religious organizations, physicians, social service agencies, therapy, etc Any moves from ethnic enclaves to other communities? Stress of change, how adapted, who helped? 120

121 Why did family migrate? What were they looking for? What did they leave behind? – Premigration history: political/economic situation in country of origin – Migration history: trauma? – Postmigration history and culture shock: arrival to US. Language, immigration, poverty? Shock of cultural values? Supportive/antagonistic community? – Migration and life cycle: age of family members when migrated, age of those left behind, change in family dynamics (children ->adult status due to language), reunifications? 121

122 Peter J. Guarnaccia, Ph.D. Rutgers, The State University of New Jersey 122

123 1.What language(s) do you currently speak with family, friends, co-workers, store clerks? 2.English skills: Speaking___ Understanding_____ Reading_____ Writing_______ 3.Spanish skills: Speaking_____Understanding_____ Reading_______ Writing________ Answer Key: 1 = fluent; 2 = very good; 3 = good; 4 = poor; 5 = no ability 123

124 1.Were you born in the United States? oYes o No If not, where? 2.How long have you lived in the United States? 3.Where does most of your core (immediate) family live? 4.How often are you in contact with your family (in person, by phone, by letter, by )? 5.Who do you turn to for advice about where to go for healthcare or other services? 124

125 1.What do you call your current health problem? 2.Have you suffered from your current health problem before? If so, what did you do about it? 3.When you were sick in your home country, what did you do? 4.When you have been sick in the United States, where have you gone for treatment ? 125

126 1.What religion are you? Do you consider yourself a religious person? 2.Have you or your family consulted a religious leader or healer about your health problems? 3.Does your religion have any beliefs that might affect your treatment (like not using certain medicines; accepting transfusions)? 126

127 Peter J. Guarnaccia, Ph.D. Rutgers, The State University of New Jersey 127

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