Cultural Competence & Mental
Health in Primary Health Care
Presented by: Ruth Tadesse, MS, RN
Date: 12/04/2014
Disclosures and Learning Objectives
• Learning objectives:
•
Explain the use of 2 cultural assessment tools
•
Discuss culturally competent interventions that
can be used when providing mental health care
in primary care setting
•
Identify 5 cultural competence clinical guidelines
Disclosures: Ruth Tadesse has nothing to disclose.
What does culture got to do with it?
• Review DSM V cultural formulation
• Review IOM reports on mental health
and addictive disorders
• Discuss different cultural assessment
tools and interventions
• Next week topic
What is the right term to use?
•
Cultural knowledge
•
Cultural sensitivity
•
Cultural awareness
•
Cultural tolerance
•
Cultural acceptance
•
Cultural encounter
•
Cultural competence
Cultural Competence Defined
“To be culturally competent doesn’t mean you are an authority
in the values and beliefs of every culture. What it means is
that you hold a deep respect for cultural differences and are
eager to learn, and willing to accept, that there are many
ways of viewing the world.”
Okokon O. Udo, PhD
http://xculture.org/cultural-competency-programs/about-cultural-competency/
“Every encounter is a cross-cultural encounter.”
Robert C. Like, MD, MS
http://rwjms.umd`nj.edu/departments_institutes/family_medicine/chfcd/index.html
• Are we similar or are we different?
Or could we just be walking in different shoes
and gaining different life experiences?
Assessment tool: Cultural Formulation Interview (CFI)
• CFI -16 questions to ask the individual patient
• Informant Version – 17 questions to ask
families/caregivers
• Supplementary Modules – comprehensive questions
including, age specific questions, spirituality &
religion, immigrants & refuges
http://www.psychiatry.org/practice/dsm/dsm5/online-assessment-measures#Cultural
CFI located in DSM-5
IOM Report on Mental Health & Addictive Disorders:
The Six Aims of High-Quality Health Care
• Safe - Avoiding injuries
• Effective – Avoiding underuse and overuse
• Patient-centered – Individual patient preferences
• Timely— reducing waits and sometimes harmful delays
• Efficient—avoiding waste
• Equitable— providing care that does not vary in quality
http://www.ncbi.nlm.nih.gov/books/NBK19817/
Why should we care about culture?
• Racial and ethnic minorities comprise 26% of
the total population of the United States.
2010 2000 1990
• In Oregon:
White
78 %
83%
91%
Latino
12%
8%
4%
African American
2%
2%
2%
Asian
4%
3%
2%
Native American
2.1%
2%
1%
Multiracial
2.8%
2.4%
ND
Other
0.1%
0.1%
0.1%
http://quickfacts.census.gov/qfd/states/41000.html
Cultural Differences in Mental Health
• Racial minorities are more likely to report depressive
symptoms to PCPs than to mental health specialists
(Snowden, 2001).
• Racial, ethnic and cultural minority fear the negative
consequences of mental health care (Inerian, et al , 2013).
• Mental health plays a major role in physical health
and vice versa (Kessler et al, 2005; Mauer, 2003; Lando et al, 2006).
Cultural Differences in Mental Health
• As many as 70% of issues in primary care setting
stem from psychosocial issues (Robinson & Reiter, 2007).
• To provide optimal care for a psychiatric patient,
modes of treatment has to be individualized (Holden
et al, 2014).
• Minority patients are among those at greatest risk
of non-detection of mental disorders in primary
care (Holden et al, 2014).
Ideals of Mental Health Dimensions of
Cultural Difference
EASTERN’
‘WESTERN’
•
Harmony with other
people (other valued)
•
self sufficiency & selfesteem valued
•
Relationships
•
Personal autonomy
•
Balance (‘ecological’)
•
Efficiency (‘machine like’)
•
Keep outer world
constant (conform with
•
Keep inner world
constant (control altered
society)
•
Freedom of inner
experience (variety of
inner experience)
www.sumanfernando.com
states of consciousness)
•
Freedom of expression
(variety in behavior)
Cultural Competence Clinical Guidelines
in Mental Health
• Explore the meaning of • Recognize that mental
the aberrant behavior
health disorders are
from the client’s point
complex and are
of view
influenced by culture
• Avoid projection of the
• Be aware of self
clinician’s worldview
cultural competence
on the client
to avoid influences of
• Be aware of the
the therapeutic
cultural context of
relationship
help-seeking behavior
Group therapy in other cultures
Assess using BATHE Method – ~1 minute
Lieberman, J. A. & Stuart, M. R. (1999)
Background
Affect
“What is going on with your life?
Tell me what has been happening
since I saw you last?”
“How do you feel about what is
going on?”
Troubles
“What troubles you about this?”
Handling of the current situation
“How are you handling that?”
Empathic response
“Sounds like things are difficult
for you.” “Let’s schedule you to
see one of our behavioral staff.”
Intervention: CRASH Course (Rust et al., 2006)
Each person is the world expert of their own condition.
•
•
•
•
•
Considering culture
Showing Respect
Assessing/Affirming differences
Showing sensitivities/self-awareness
Do it all with Humility
What is the danger of not considering culture of the
patient?
To be continued…
Next Week's
Topic:
Psychopharmacology with
Dr. Betlinski or Dr. Hamer
The human mind is like an umbrella.
It functions best when it is open.
–Max Gropius
References
Center for Healthy Families and Cultural Diversity Department of Family Medicine/UMDNJ
-Robert Wood Johnson Medical School www2.umdnj.edu/fmedweb/chfcd/INDEX.HTM
Cross Cultural Health Care www.xculture.org
CultureMed www.sunyit.edu/library/html/culturemed/
Culturally and Linguistically Appropriate Services (CLAS) United States Department of Health and Human
Services Office of Minority Health www.omhrc.gov/clas
Diversity in Medicine www.amsa.org/div
Ethnomed http://healthlinks.washington.edu/clinical/ethnomed
Holden, K., McGregor, B., Thandi, P., Fresh, E., Sheats, K., Belton, A., Mattox, G., & Satcher, D. (2014). Toward
Culturally Centered Integrative Care for Addressing Mental Health Disparities Among Ethnic Minorities.
Psychological Services. 11(4). pg. 357-368.
Ideals of Mental Health Dimensions of Cultural Difference www.sumanfernando.com
Initiative to Eliminate Racial & Ethnic Disparities in Health
http://raceandhealth.hhs.gov
Institute of Medicine (2005). Improving the quality of health care for mental and substance-use conditions:
Quality Chasm Series. Washington, DC: National Academies Press.
Institute of Medicine (2001). Unequal Treatment: What Healthcare Providers need to Know About Racial and
Ethnic Health Disparities. Quality Chasm Series. Washington, DC: National Academies Press.
References
Initiative to Eliminate Racial & Ethnic Disparities in Health
http://raceandhealth.hhs.gov
Lieberman, J.A., & Stuart, M. R. (1999). The Bathe Model: Incorporating Counseling and Psychotherapy Into
the Everyday Management of Patients. Primary Care Companion Journal of Clinical Psychiatry 1(2): pg. 3539.
Mental Health: Culture, Race, and Ethnicity: A Supplement to Mental Health: A Report of the Surgeon General.
http://www.ncbi.nlm.nih.gov/books/NBK44246/
National Center For Cultural Competence (NCCC) www.georgetown.edu/research/gucdc/nccc/
“Race” and Culture Issues in Mental Health and Thought Identity
http://webcache.googleusercontent.com/search?q=cache:NhVH6TEqdIAJ:www.oise.utoronto.ca/cdcp/Us
erFiles/File/Conferences%26Seminars/Conference%2
Resources for Cross-Cultural Health Care www.diversityrx.org
Rust, G., Kondwani, K., Martinez, R., Dansie, R., Wong, W., Fry-Johnson Y., & Strothers, H. (2006). A CRASHCourse in cultural competence. Ethnicity & Disease, 16(2, Suppl.3), S3-29-36.
Searight, H., R., (2009). Realistic Approaches to Counseling in the Office Setting. American Family Physician.
79(4): pg 277-289.
Transcultural and Multicultural Health Links http://web.nmsu.edu/~ebosman/trannurs/index.shtml