1. Cultural Competence Integrating Differences into Community Services

2. Objectives Understand Stigma. Understand Culture Competency. Learn Culturally competent care for people with Mental Health, Mental Retardation and Addictions.

3. We live in an world which often separates us. Racism Sexism Ageism Feminism Classism Atheism

4. “Different” people are “Stigmatized” Mentally retarded inmates in a sanitorium in Germany

5. Stigma Definitions from the U. of Chicago PSR Training Manual “Stigmas are negative attitudes about a group that lead to depriving them of some fair opportunities.”

6. Stigma is related to….. Stereotypes Prejudice Discrimination

7. Stereotypes from The Asian Health Coalition of Illinois Stereotypes are exaggerated beliefs or fixed ideas about a person or group which is held by people and sustained by selective perception and selective forgetting.

8. Prejudice from The Asian Health Coalition of Illinois Prejudice is a preconceived idea or negative attitude formed before the facts are known and sustained over generalizations. A bias without reason, resisting all evidence…

9. Discrimination from The Asian Health Coalition of Illinois Discrimination refers to treatment in favor or against a person based on the group to which that person belongs and not on merit.

10. Stigmatized People….. Experience being stereotyped and are often the object of discrimination and prejudice.

11. People are often stigmatized by: Mental Illness Mental Retardation Physical Disability (including blindness, deafness) Alcoholism /and or Drug Addiction HIV or AIDS, Cancer or other terminal illnesses Criminal behavior Poverty Alternative Lifestyles/sexual orientation Wheelchair bound Gender Obesity

12. stigmatized groups! All our Consumers belong to

13. Stigmatized People Consumers and their families can’t navigate the bureaucracy even if resources are there. It’s too frustrating!

14. Use People First Language “I am more than my illness….Don’t call me “the schizophrenic, “the addict” or “the retard.”

15. As human beings, we have many similarities….. But, who we really are, is often derived from our original family of origin and our current lifestyle.

16. The Bottom Line: People are different, even within their own culture! These differences matter when planning and providing services.

17. National Mental Health Association “For Mental Health consumers, both access to the services and the effectiveness of the care they receive are greatly affected by the degree to which the delivery system is“culturally competent.”

18. Some important definitions Related to Cultural Competency

19. Culture from King,et. al The Office of Special Programs, U.S. Dept. of Education “The integrated patterns of human behavior that includes thoughts, communications, actions, customs, beliefs,values, and institutions of racial, ethnic, religious, or social groups.”

20. Cultural Sensitivity An awareness and respect of a person’s cultural beliefs and values. Culhane-Pera, et.al

21. Cultural Competency Skills (that translate into) Behaviors, Practices, Attitudes, and Policies That enable an individual, agency, or system to effectively serve culturally diverse communities. from The Asian Health Coalition of Illinois

22. Here at Hill Country MHDDC Consumers are very diverse in their language and culture.

23. 61% of our Consumers are Caucasian Americans Many have German backgrounds.

24. Our Consumers are ….. 33% Hispanic 1% NativeAmerican 3% African American 1% Asian n

25. 1% are “Others”

26. Consumers Have Many Different Lifestyles

27. Lifestyles

28. They have many different beliefs.

29. Can We Communicate? Think Language first! Do we need an interpreter? Communicate respectfully. Be sensitive to the consumer and the family. Consider your dress, tone of voice, eye contact, location, seating arrangement, privacy, etc.

30. Is our approach culturally appropriate? “What do you call your problem?” “What name does it have?” “What do you think caused your problem?” “Why do you think it started when it did?” From Arthur Kleinman’s question protocol in“Culture,Illness, and Care: Clinical Lessons from Anthropologic and Cross Cultural Research”, Ann.Intern.Med. 1978:Vol.88, pg.251-258

31. Important Issues to Consider… Impact of religion. How are women, men, elders, and children treated in their culture? Is there domestic violence? Ethnic minorities generally underutilize outpatient services, although African-Americans are over-represented in inpatient setting.

32. Diagnosis Minorities with Bipolar Disorder are often diagnosed with schizophrenia. (Mukherjee,et al) African Americans are over diagnosed with schizophrenia and under diagnosed with mood disorders. (Bell ) A mental health consumer’s addictions may not be treated. The elderly may not be assessed for substance abuse or alcoholism.

33. Diagnosis A person with a primary addiction problem might not be treated for a co-occurring mental illness.  Learning disabilities may not be identified in individuals with mental illness or substance abuse.  A person with mental retardation may not be treated for mental illness or substance abuse.

34. Diagnosis Post Traumatic Stress Disorder is often undiagnosed in people suffering from Domestic Abuse or other trauma. Children who are witnessing or are victims of domestic abuse or another trauma, may be misdiagnosed with Attention Deficit Hyperactivity Disorder.

35. Medication Differences Asians and Hispanics need lower doses of anti- psychotics. African Americans use the same doses of anti- psychotics, but lower doses of lithium. The elderly need lower dosages of medications. Thus, metabolism of drugs varies with age and ethnicity and is critical in prescribing medications. From “Making Room for Culture in Psychiatry” by Lin, et al.

36. Pain Tolerance Men and women tolerate pain differently. Cultures tolerate pain differently. People with addictions develop a hypersensitivity to pain. In certain cultures, self-inflicted pain is a part of a religious experience.

37. Religion Religious beliefs shape how the world is viewed. Is illness a punishment? The devil’s work? An evil spell? Bad karma? For Hispanics, the curandero is a trusted healer. For Lakota Sioux, the ritual Vision Quest, praying and fasting at a holy site is life changing.

38. Remember there are as many differences Between individuals in the same culture as there are between individuals in different cultures!

39. Two African American families, one lesbian and the other, multi-racial.

40. German Consumers Suggestions from our Gillespie County MH staff What generation German? Would they feel more comfortable speaking in German? A consumer reacting to internal stimuli.

41. German Consumers Suggestions from our Gillespie MHC staff in Fredericksburg  They may be resistant to seeking mental services.  They may be reluctant to take medication.  They may “keep things within the family.”  They are concerned about the stigma.

42. German Consumers They may feel it’s a character flaw or a disgrace. They are very concerned about confidentiality. Drinking alcohol is an accepted part of their culture. Teen drinking may be acceptable in their family.

43. Hispanic Consumers from the U.S. Census, 1/23/03 Houston Chronicle Hispanics are the largest minority group in the U.S. with 37 million people. Texas is approximately 32 percent Hispanic 11.5 % African American, 3.3% Other 53.1% Anglo

44. Treatment Issues for Hispanic Consumers  Do we need an interpreter?  Is the person Tejano or from Mexico?  What generation Hispanic?  Is the person using a curandero?

45. Treatment issues for Hispanic Consumers Hallucinations are natural in their religion. Hearing the voice of a loved one or having hallucinations might be an expectations when celebrating the Day of the Dead. Hispanic families are patriarchal.

46. Hispanic Consumers and The Day of the Dead  A man is dressed in a skeleton costume to portray death in a celebration of Dia de los Muertos, The Day of the Dead.  People visit the graves of their dead relatives to honor them.

47. Native Americans

48. Treatment Issues for Native American Consumers  Impact of racism,unemployment,and poverty.  Coping with reservation life and assimilation in mainstream culture.  Consider the obesity, diabetes, hypertension, and alcoholism in adults and fetal alcohol syndrome in children.  High use of native healers in the Southwest.

49. African Americans

50. African Americans from the Houston Chronicle, 1/23/03 There are 36.2 million Americans who identify themselves as “black only.” 37.7 million identify themselves as “black and at least one other race.” 11.5% of Texans are African Americans.

51. Treatment Issues for African American Assess for co-occurring substance use disorders and alcoholism. Address complications of obesity, hypertension, diabetes,congestive heart failure, asthma, and cancer. Sickle cell anemia is another illness specific to African Americans.

52. Treatment Issues for African Americans Matriarchy; Mom or grandmother are the dominant family figures. Lack of male role models and intact families. Extended family or the Church may be supports.

53. Treatment Issues for African Americans There is discrimination within their own group based on skin color, hair texture, class, values, etc.

54. Treatment Issues for Asians  Asians rarely seek help until its very severe.  Asians have extremely low admissions to state hospitals.  Mental illness is considered shameful. It’s hidden.  Is an interpreter needed?

55. Treatment Issues for Asians Focus on physical symptoms. Asians are sensitive to medication. Give ½ the standard dose. Asians may use traditional healers and herbal medicine. Asians may “flush” when drinking alcohol.

56. Asian Consumers Acupuncture has been used to treat pain, schizophrenia, depression, and addictions.

57. Treatment Issues for Asians Asian Cultures are patriarchal. The males in the family have the authority. Asians are more formal and inhibited in their social behavior.

58. Older Adults

59. Treatment Issues for Older Adults  Are they aware they need help?

60. Treatment Issues for Older Adults Is their mental illness caused by medicine? Do their medical problems cause or complicate their mental illness? Is there Elder Abuse?

61. Gay Men and Lesbian Women  May struggle with homophobia and“being in the closet” at work and with their families.  Gay people may want marriage, children, partner benefits, etc., but may endure legal barriers.

63. Gay and Lesbian Women Gay people often have specific health issues related to their sexual practices. HIV, AIDS and STD’s are still concerns with Gay men. People may be grieving the death of a partner or friends who’ve died from AIDS, or coping with living with AIDS or being HIV+ themselves.

64. Treatment Issues for Gay and Lesbians Explore childhood abuse issues and Domestic Violence.. Assess for substance use and alcoholism. Sex enhancing drug use may be common among some gay men.

65. Physically Challenged  Can they get to treatment?  Deal with their frustration and depression Re: their disability.  Do they need vocational assistance?

66. Mentally Challenged

67. Treatment Issues of Mentally Challenged They need to have meaningful activity and purpose in their lives. They need to feel acknowledged and appreciated. They need safety, structure, and security. Lack of continuity can cause crisis! They may need vocational assistance.

68. Winona Ryder December 12, 2001, Winona Ryder shoplifted $5,560.40 designer items from Saks Fifth Avenue in Beverley Hills. Twice an Academy Award Nominated actress

69. She had the following 8 drugs in her possession: Liquid demerol Liquid Diazepam Vicodin Percodan Valium Morphine sulfate Endocet (containing Oxycodone)

70. Patterns of Drug Use are highly Regional. Drugs, routes of administration, street names, patterns of use, and drug combinations may differ greatly, not only between individuals from different cultures, but different parts of the country or even different parts of the city.

71. Drugs of Choice Native Americans-alcohol Asians-gambling, work Gay Men-stimulants, amyl nitrate, ecstasy “Rich”-prescription drugs, Internet porn M.D.’s –Vicodin

72. Drugs of Choice Young adults-marijuana, cigarettes Geriatrics-alcohol, pills Sex Workers-crack cocaine, IV speedballs Screen mentally retarded for abuse too!

73. How Do We Best Serve Our Consumers? Examine own stereotypes. Build trust. Use People First language!

74. How do we best serve our consumers? Pronounce the person’s name correctly. Get an interpreter, if necessary. Educate yourself from the consumer, his family, co-workers, etc. Remember differences do matter!