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Improving Mental Health Service Delivery to Hispanics

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1 Improving Mental Health Service Delivery to Hispanics
National Resource Center for Hispanic Mental Health® Changing Minds, Advancing Knowledge, Transforming Lives™ Improving Mental Health Service Delivery to Hispanics 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 Training Held on May 5, 2012 on behalf of the agency’s project: Partners for Culturally Competent Behavioral Health Service Delivery to Hispanics

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 today’s training or any other program development or intervention activities

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

4 Agenda 10:00 am-10:15 am Welcome, Overview & Introductions: Henry
10:15 am-10:45 am Assessing Diversity among Latinos: Peter 10:45 am – 11:00am Break 11:00 am-12:30 pm Latino Mental Health: Focus on Depression and Its Treatment: Igda 12:30 pm-1:30 pm Lunch 

5 Agenda 1:30 pm-2:30 pm DSMIV, Cultural Formulation and Latinos: Peter
2:30 pm – 2:45 pm Break 2:45 pm-3:30 pm Using Genograms to Elicit Cultural & Family Issues: Igda 3:30 pm-3:45 pm Social & Cultural Assessment of Hispanics: Peter 3:45 pm-4:00 pm Evaluation & Wrap-Up

6 Assessing Diversity Among Latinos
Peter J. Guarnaccia, Ph.D. Rutgers, The State University of New Jersey

7 Hispanic Identity Question

8 Race Question

9 ¿Hispanic or Latino? 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

10 Who are Latinos in New Jersey?
10 Source : U.S. Census, 2000

11 National Latino & Asian American Study (NLAAS)
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

12 Methods 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

13 Demographics - Age Cubans are significantly older than the
other Latino groups

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

15 Demographics - Education
Mexicans have less education than the other Latino groups

16 Demographics – Income Mexicans have significantly lower incomes
than the other Latino groups

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

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

19 Migration – Number of Parents Born in the U.S.
More likely that both parents born In US than 1 parent; Cubans least likely to have US born parents

20 Migration – Percentage of Life in US
Puerto Ricans have spent more of their life on the U.S. mainland

21 Migration – Wanted to Move
Cubans were the only group where a large majority expressed a desire to move to the US

22 Migration – Move Planned
Cubans were more likely to have carefully planned their move to the US

23 Reasons for Migration % Very Important Reason for Move Puerto Rican
Cuban Mexican Other Latinos p Employment 66 52 75 65 .001 Join Family 51 53 48 .75 Improve Future for Children 78 84 79 .05 Political Situation 9 91 17 34 Seek Medical Attention 22 8 12 .003 Seek Education 60 56 62 .42 Family Problems 10 6 5 .03

24 Migration – Ease of Visiting Relatives/Friends
For Cubans visiting relatives in their home country was very difficult. For Puerto Ricans it was easy.

25 Language of Interview 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.

26 General Language Use 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.

27 Language Spoken as Child
Overwhelmingly, everyone spoke Spanish as children.

28 English Proficiency- Spoken Language
Puerto Ricans are most English proficient; Cubans are least.

29 Spanish Proficiency – Spoken Language
Cubans are most Spanish proficient, with the other groups being similar.

30 Ethnic Identity – Identification with Others from Your Group
Everyone identifies closely with their Latino group.

31 Ethnic Identity – How Important to Marry Others from Your Group
Relatively few think it is important to marry within their Latino group.

32 Sociocultural Change – Acculturative Distress Scale
Puerto Ricans experienced significantly lower acculturative distress; Mexicans reported the highest levels of acculturative distress.

33 Sociocultural Change – Family Cultural Conflict Scale
Puerto Ricans reported significantly higher levels of Family Cultural Conflict than Cubans or Mexicans

34 Sociocultural Change – Difference in Social Position
Puerto Ricans and Other Latinos report a significant decline. Cubans on average report a slight increase in social position in the US.

35 Concluding Thoughts on Acculturation
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 people’s 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.

36 Concluding Thoughts on Acculturation
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

37 Concluding Thoughts on Acculturation
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

38 Concluding Thoughts on Acculturation
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

39 Concluding Thoughts on Acculturation
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

40 Cultural Issues in Latinos’ Experience with Depression
Igda E. Martinez, Psy.D. Albert Einstein College of Medicine

41 Why migration leads to depression
“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” It’s like losing the roof over your head, losing everything, it’s as if one had gone through an earthquake and lost everything … it’s an accumulation of losses

42 Goals of Research 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

43 Methods 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

44 Methods 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

45 What is Mental Health? 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 one’s emotions and not being aggressive Not abusing alcohol or drugs

46 Comments about “Mental Health”
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, that’s the most important … to feel a sense of well-being about my family’s unity and to live peacefully

47 What is Depression? 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 11th Depression often connected to diabetes (and other conditions such as high blood pressure)

48 Recognition of Depression
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 doesn’t know why, s/he has no desire to do anything. One doesn’t have friends, doesn’t have family or anything. When you feel like this, you miss your family even more.

49 Recognition of Depression
[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.

50 Barriers to Care 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 husband’s insurance doesn’t cover this, we need a $250 down payment.

51 Barriers to Care [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 don’t have papers; we don’t have information about many things; we don’t know what our rights are … Life here is very difficult. We are very isolated here.

52 Attitudes Towards Seeking Help
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. It’s due in part to ignorance, not being able to understand depression, and not knowing where to go for help.

53 Attitudes Towards Providers
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]

54 Attitudes Towards Treatment
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... I’ve 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...

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

56 Attitudes Towards Treatment
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

57 Attitudes Towards Medications
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

58 Attitudes Towards Medications
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.

59 Improving Care for Depression
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

60 Needs for Community Intervention
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

61 Call to Action! “¿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!

62 Latinos and Depression
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) In addition, Latinos have very low rates of use of mental health services Latinos have lower rates of treatment adherence Disparities in mental health treatment continue to exist Latinos in general have lower rates of depression compared to Whites. Puerto Ricans tend to have higher lifetime prevalence compared to Mexicans, Cubans, and other Latinos.

63 Latinos and Treatment 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 life’s 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 This research shows that when accessing services, minority group members need to determine whether or not they will feel comfortable in the treatment setting and with their individual provider. For example, they need to verify if their narratives, value systems, coping strategies, and experiences with discrimination will be understood in a flexible manner by their psychiatrist. Latinos were more likely than whites to have negative beliefs about antidepressants, for example believing that they are addictive and disagreeing that they are effective. Martínez and Guarnaccia (2007) completed a series of focus groups with Latinos. All were community samples recruited through a range of community mental health and social service agencies as well as community resources such as churches and day care centers. Overall there were 94 participants in 12 different groups throughout New Jersey and New York City.

64 Overall Study 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

65 Purpose of Study What cultural values influence people’s 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? Based on the literature, I expected values such as respeto (respect) to influence their adherence with antidepressant medications. I expected family to be involved in patient’s treatment. Today, I will specifically focus on the cultural value of familismo and the related topic of family influence.

66 Familismo (Defined) 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 The term familism was created about 60 yrs ago “normative commitment of individuals to their family and family relationships” On several studies, Latinos have come out higher on various indices of family comitment,indicating its importance and relevance for Latino health research. Family relationships for Latinos tend to include members outside of the nuclear family, and individuals are generally raised to be dependent on the family (vs Anglos, where individuals are raised to be independent of their family). Researchers have identified two domains of familism that are important to understand: attitudinal and behavioral (Villarreal, Blozis & Widaman, 2005). Other studies have tried to break down attitudinal familism, and found to be made up of 4 constructs: familial support, familial interconnectedness, familial honor, and subjugation of self for family. (Lugo Steidel & Contreras, 2003). It is this last construct that most interests me. They defined it as the belief that a person must yield and be submissive to the family. Items: Person should always support family members in need, even if big sacrifice. Person should often do activities w family members. Person should be expected to always defend family honor no matter what. Person should respect older siblings regardless of different pov. Person should be a good person for sake of family. Children should obey w/o questioning even if they think parents are wrong. I argue that familism is a dynamic concept, that is more complex than just valuing the family unit. For people with mental illnesses such as depression, the value of familism can in fact become somewhat of a burden and create negative pressures. This can lead to patients covering up their symptoms or their illness severity in order to protect the family, to not burden them.

67 Family influence (Defined)
Instances in which family was mentioned Not necessarily describing the overall value of familismo. Tendency to focus more on instrumental support Important in the individual’s conceptualization of depression or its treatment Directly challenged or influenced client’s understanding or behavior.

68 Research Procedure 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

69 Sample Characteristics
80% female Age range 27-66 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 The inclusion criteria for participation in this study were that participants needed to be self-identified Latinos between the ages of 18 and 65, carry a primary DSM-IV diagnosis of major depressive disorder, and be currently taking antidepressant medications.

70 Cultural Considerations: Familismo and Family Influence
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)

71 Familismo Expressed Queremos mucho a los hijos, los papas, todo, como queremos estar siempre unidos…y todavía se casan y uno quiere los nietos y to’l 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 one’s grandchildren and everyone … to join together in the family, we are very united families.

72 Respeto 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 don’t like about here…one can’t say anything to one’s children…they do whatever they want…here there is no youth and the children are the parents, in a way. They don’t obey or nothin’. In our countries, no. Even in my old age I obeyed my mom and my dad.

73 Caretaking/Functioning
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.

74 Caretaking/Functioning
…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.

75 Protecting Family from Personal Problems
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. a Mexican male in his mid 20s, went on to say that not only is it better to hold back experiences and the negative emotions associated with depression, but that it is best to withhold that information for the good of the family.

76 Protecting Family from Personal Problems
… 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.

77 Family Influence 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. This was how we originally defined family influence when we were coding the transcripts. However, one question that I pose to you today, is whether you find that this definition significantly differs from what I just defined to you as familismo. Keep this question in mind as I present to you what I see as instances of positive and negative family influences, which DIFFER from familismo as a value. Then I will present to you several quotes that were originally coded as family influence (Not familismo), but which I am unclear if the distinction is clear.

78 Treatment Supportive Family Influence
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 don’t have time, she always tries to pay attention, she says to me, ‘Do you have the pills with you?’

79 Treatment Supportive Family Influence
Y mi hermana fue la que me llevo y yo estaba como muy, pa’donde 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, “What’s that for?”and then she’d say, “To cure you, so you can be well, like before.”

80 Treatment Discouraging Family Influence
…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, let’s say. It was something that was out of my hands.

81 Treatment Discouraging Family Influence
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 I’ve had and I’ve 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 can’t with mine.’”

82 Summary 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. Familismo was not specifically asked about in our focus group protocol. Participants mentioned on their own the various ways in which families were involved in their lives, with specific reference to their experience of depression

83 What did we learn? What cultural values influence people’s decisions to take medications or not? Familismo Religion Poner de su parte (Do one’s part) Trabajar/luchar/aprovechar (Work/Struggle/Take Advantage)

84 Clinical Implications
Clinicians need to be culturally sensitive It is not always wise to include or exclude family members in treatment Should listen to the patient’s 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 family’s role in their own treatment.

85 DSMIV, Cultural Formulation and Latinos
Peter J. Guarnaccia, Ph.D. Rutgers, The State University of New Jersey

86 Guidelines: Complementary Cultural Formulation
Cultural Identity of the Client Cultural Explanations of the Client’s 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

87 Guidelines: Complementary Cultural Formulation
Cultural Explanations of the Client’s 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

88 Ataque de Nervios 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

89 Ataque de Nervios 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.

90 Ataque de Nervios 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

91 Relationship between Ataque de Nervios & Psychiatric Diagnosis
Guarnaccia, et al., 1993, JNMD

92 Phenomenological comparison of ataques and panic disorder
Ataques distinct from PD Common to Ataques and PD Provoked Crescendo > 10 minutes Followed by relief Recurrence Symptoms during episode Fear during episode Sequelae

93 Association between Ataques de Nervios and Psychiatric Disorder in Puerto Rican Children
Community Sample (n = 1891) Diagnoses Absence of AdN (n=1723) Presence of AdN (n=168) 2 Any Depression 33 (2.3) 16 (15.2) 8.11** Any Anxiety 87 (5.4) 38 (22.1) 17.88*** Any Disruptive 171 (9.7) 39 (24.8) 12.09*** Any Diagnosis 243 (14.0) 62 (40.9) 24.43*** Any Impairment 196 (10.5) 55 (39.6) 19.20*** Guarnaccia, et al., 2005, JAACAP

94 Association between Ataques de Nervios and Psychiatric Disorder in Puerto Rican Children
Clinical Sample (n = 757) Diagnoses Absence of AdN (n=563) Presence of AdN (n=194) 2 Any Depression 39 (7.0) 57 (30.2) 45.66*** Any Anxiety 83 (14.6) 72 (37.7) 35.53*** Any Disruptive 190 (33.4) 98 (50.7) 18.50*** Any Diagnosis 251 (44.7) 125 (65.4) 27.75*** Any Impairment 245 (44.1) 118 (62.4) 21.55*** Guarnaccia, et al., 2005, JAACAP

95 Relationship of Ataques de Nervios to Mental Health (NLAAS)
*** *** *** *** Guarnaccia, et al., 2008

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

97 Susto 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

98 Susto 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.

99 Susto 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

100 Susto across Latino groups
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

101 Relationship of susto to psychiatric disorders
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 Interpersonal Depression Feelings of loss, abandonment by family, sadness, poor self image, suicidal ideation Traumatic event PTSD Somatic symptoms Somatoform Health care from several practitioners Taub, 1992

102 Susto in an urban clinic in Mexico
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., 2005

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

104 Video Excerpt and Discussion on the use of Interpreters in Mental Health Setting
Source: Communicating Effectively Through an Interpreter. Cross-Cultural Health Care Program, Seattle, WA, 1998.©

105 Toward DSM-V 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

106 Relationship among Anxiety, Depression and Cultural Syndromes
Dissociation Anxiety Depression Cultural Syndrome Somatization

107 Clinical Examples of the Cultural Formulation

108 Cultural Identity 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

109 Cultural Explanations of Illness
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

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

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

112 Overall Cultural Assessment
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

113 Using Genograms to Elicit Cultural and Family Issues
Igda E. Martinez, Psy.D. Albert Einstein College of Medicine

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

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

116 Finances 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

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

118 Belief Systems, Religion, Spiritual Beliefs
What primary beliefs organize the family? What is the history of the family’s beliefs, what have been the changes, if any? Reactions to changes in the family? Differences within the community?

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

120 Connections to Community
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?

121 Migration History 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?

122 Social & Cultural Assessment of Latinos
Peter J. Guarnaccia, Ph.D. Rutgers, The State University of New Jersey

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

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

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

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

127 The State University of New Jersey
Evaluation & Wrap-Up Peter J. Guarnaccia, Ph.D. Rutgers, The State University of New Jersey

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