Reinventing Ourselves as Mental Health
Clinicians When Working with Refugee and
Immigrant Populations
October 31, 2008
MIAB Conference
The $ and Sense of Culturally Effective Care: Access,
Communication, and Commitment
Zarita Araújo-Lane, LICSW
Cross Cultural Communication Systems, Inc.
Tel: (781) 729-3736 ext.105
Email: zaraujo_lane@cccsorg.com
What does this sign tells you?
PERCEPTIONS
Perception Towards Your Assistance
Goals
•To understand your clinical construct
•To understand how to work with interpreters
•To understand how to engage and treat
immigrant and refugee populations
Goal # 1
To understand your clinical construct
Providers vs. Helpers
adapted from Randall-David (1989)
 Counselors
 Psychiatrists
 Psychologists
 Social Workers
 Ministers
 Curanderos
 Ministers
 Root Workers
 Vodoo Priests
 Medicine Men
 Herbalists
 Family / Friends
 Espiritistas
“…mentally ill patients have the
right not to be abused but also
they have the right to the best
available mental health care”
(Adopted by the General Assembly of the United Nations,
.
1991) Copied: Ethics Culture and Psychiatry by Okasha et
al, 2000
Declaration of Madrid,1960-1970
Mental Health Programs
 A need for strategy ‘s
 Programs need to not only
treat and rehabilitate but
also promote mental
health
temporal validity.
(constant evaluation of
short and long term
goals)
 A need to develop a
collaborative approach
with other professional
community members and
families
Copied: Ethics Culture and Psychiatry by Okasha
et al, 2000
Autonomy vs. Collectivism
Adapted from Derald Wing Sue and David Sue (2003)
Guilt
‘when individuals engage in
wrongful behaviors and this
is a type of an individual
experience’
Shame
‘when individuals engage
in wrongful behaviors and
this is a type of collective
(family, friends, community)
experience’
STIGMA a FORM of SHAME
 How is the community
going to perceive the
fact that I need Mental
Health Services?
 How is my family
going to perceive the
fact that I need Mental
Health Services?
Stigma/Shame
“I Must Have Done Something
Wrong…”
“I Should Pay for My Sins…”
“There is Nothing You or I Can DO…”
And now EVERYONE in my
family and community…
is going to know what I have done!
These are the words of many
patients who were referred to out-patient mental
health services for evaluations and treatment.
In Summary:
 Patient and or family who may feel shame
or guilt and do not seek help
 Mental Illness can be perceived as a
punishment or bad karma
 Patient sees illness in a fatalistic way
Adapted: Clinical Manual for Cultural Psychiatry by Dr. Lim, 2006
Precipitant Factors for Referrals
 Chronic illnesses, yearly check-ups
 Children with academic problems
 Children with behavioral problems
 Couples struggling with staying together
 Alcoholism in the family
 Mental illness
 Inability to keep up with work demands
Referral Sources
 Community Organizations with key community
advocates that speak the patient’s language
 Community Health Centers and Pediatricians or
Primary Care Physicians
 Schools with Special Education Departments
 Court Systems and Probation Officers or CAB
 Emergency Rooms
 Other Community Members
Building Trust
Fundamentals of trust
 Competence
 Sincerity
 Involvement
Copied from Business Design Associates, Inc. 2002
We all have a need to feel and express:
 Honor
 is a sense of worth or dignity
that is defined by actions
prescribed in a person’s
traditions, rituals or history.
Generosity
A willingness to do something out
of the ordinary that creates the
sense of common ground with
another.
Respect
Respect is the acknowledgement
of a person’s roots through a
behavior
Trust
Trust is a feeling or assessment
that is evoked in a person
involved in an interpersonal
interaction. person’s roots
Respect Means Honoring Boundaries

“Respect also means honoring people’s boundaries
to the point of protecting them.”
(Copied from Dialogue and the Art of Thinking Together by William Isaacs,1999,
Random House Publishing)
Respect Means Honoring Boundaries
“If you respect someone, you do not intrude.”
(Copied from Dialogue and the Art of Thinking Together by William Isaacs,1999,
Random House Publishing)
Respect Means Honoring Boundaries

“ At the same time, if you respect someone,
you do not withhold yourself or distance
yourself from them.”
(Copied from Dialogue and the Art of Thinking Together by William
Isaacs,1999, Random House Publishing)
Eliciting the patient’s model of illness as per Dr.
Kleinman Dialogue with the patient
 What do you think
caused your problem?
 Why do you think it
started when it did?
 How bad (severe) do
you think your illness
is?
 What do you think
your sickness does to
you?
 Do you think it will
last a long time, or will
it be better soon in
your opinion?
Dr. Kleinman’s Model
 What kind of
treatment would
you like to have?
 What are the chief
problems your
illness has caused
you?
 What are the most
important results  What do you fear
you hope to get
most about your
from treatment?
Pay attention to the story!
 Use same words as the patient, at first, as a
way of showing that you are listening!
Cultural Formulation
cultural identity of the individual
and
cultural explanations of the illness
What is culture?
According to Fergurson ( 1991)
Culture is interactional and dynamic.
(just one aspect of an individual’s identity;
along with others aspects such as gender,
age, and class)
What is culture?
According to Bonder et all (2002)
Culture is learned.
We are shaped by the belief
systems around us.
One is not born with
knowledge of a culture
What is culture?
Huges (1976) defined culture as a
“learned configuration of images and other
symbolic elements (such as language) widely
shared among members of a given society or
social group which, for individuals, functions as
an
orientational framework for behavior.”
Culture
 Written Rules- laws, codes, standards
 Unwritten rules- mores
 World View- a set of assumptions about a
person’s environment
What is culture competency?
According to CLAS Standards
Being able to recognize and respond
to
health–related beliefs and cultural
values, disease incidence and
prevalence and treatment efficiency
What is culture competency?
 On-going assessment of how one’s own
values interact with the other person’s
values.
 The ability to live with the fact that there
are many sides (truths) to a story.
What is culture competency?
 Paying attention to the individual.
 Connecting around the other person’s
thinking by echoing it.
Transference and
Countertransference Issues
Understanding your and the patient’s
worldview
Transference
Interethnic / Intraethnic effects
 Overcompliance
 Omniscient-omnipotent
therapist
 Denial of ethnocultural
factors
 The traitor
 Mistrust
 Autoracism
 Hostility
 Ambivalence
 Ambivalence
Adapted: Clinical Manual for Cultural Psychiatry by Dr. Lim, 2006
Countertransference
Interethnic / Intraethnic effects
 Denial of Etnhocultural
 Overidentification
factor
 Clinical Anthropologist
syndrome
 Guilt or pity
 Aggression
 Ambivalence
 Distancing
 Cultural Myopia
 Ambivalence
 Anger
 Survivor’s guilt
Adapted: Clinical Manual for Cultural Psychiatry by Dr. Lim, 2006
Four Layers of Diversity:
Organizational
Dimensions
External
Dimensions
Internal
Dimensions
Personality
Geographic Location
Race
Functional
Level/Classifications
Income
Age
Personal Habits
Gender
Work Content Field
Recreational Habits
Ethnicity
Division/Department/
Unit/Group
Religion
Sexual Orientation
Educational Background
Physical ability
Seniority
Work location
Union Affiliation
Management Status
Work Experience
Appearance
Parental status
Marital status
Copied from: Gardenswartz, Lee and
Rowe, Anita. Managing Diversity. MC
Graw-Hill. 1998
Three Culture Patterns
Dependent
Interdependent
Independent
Authority
(Not Equal,
hierarchical)
Equal
Equal
Time
Circular
(past and present
external control)
Circular and Linear
Linear
(present and future,
internal control)
Community
More important
Community is
than the individual important, as is the
individual
Individual first,
then others
Copied from: Carr-Ruffino, Norma. Managing Diversity. Thomson Publishing's, 1995
Four Character Values
by CCCS
 Honor
 Respect
 Generosity
 Trust
Developed by CCCS, Inc. 1996
Goal # 2
To understand how to work with interpreters
Accuracy in Mental Health interpretation
The understanding and conversion of meaning
From source to target language.
The understanding of purpose for session
The understanding of silences
Interpreter Roles
 Conduit

Clarifier

Culture broker

Patient advocate
Bridging the Gap Manual
The Triadic Relationship
Pre-session
(CIFE)
C
I
F
E
onfidential
first person
low
verything will be
interpreted
Session
Interpreter
• Manages the flow
• Has good listening skills
• Is able to project voice
• Is able to check-in when in
doubt (clarification)
Post- session
• Makes sure that patient understood
Interpreter
•
Follows patient to the other visits
if approved by institution
• Assists scheduling future
Appointments
• Requests consult with provider if
necessary
Accuracy
No______
 omissions
 additions
 false fluencies
 distortions
Goal # 3
To understand how to engage and treat
immigrant and refugee populations
Initiating Conversation Towards
Trust
 Work with patient’s conceptual system regarding
the seeking of mental health care services
 Negotiate and Compromise
(location, language, gender, confidentiality,
interaction in community)
 Involve key players
(community, religious, family, work, etc.)
Four Character Values
 Honor
 Respect
 Generosity
 Trust
Three Cultural Patterns
Dependent
Authority
Not Equal
Interdependent Independent
Equal
Equal
Circular and
Linear
Linear
Hierarchical
Time
Circular
past + present
external control
Community
More important
than the individual
Community
important,
but so is the
individual
present + future
internal control
Individual first,
then others
Somatization
a culturally competent way of communicating:
no separation between body and soul
Providers Building Bridges
building bridges is often an active role
 Acknowledge patient’s story by being a good listener
 Understand patient’s relationship with the community
and the referral source
 Stay with the patient’s story and ask for clarification
Providers Building Bridges
 Empathize with patient’s stigma, shame and fears
 Help patient develop strategies to overcome
stigma
 Acknowledge loss of present role if patient
engages in treatment
 Explore with patient alternative ways of feeling
connected with the community and with his or her
role
Providers Building Bridges
 Understand patient’s own immigration
history
 Be flexible
 Use story telling as a form of
externalization
Providers Building Bridges
You can illicit information, be educated by patient or
patient’s representative…
You can coach and negotiate a comfortable
compromise…
but you cannot change the value of a stigma or
shame without disarming the patient from his or
her honor…acknowledge, accept and work with it!
In Summary:
Essential components of culture






Culture is learned.
Culture refers to a system of meanings.
Culture acts as a shaping template.
Culture is taught and reproduced.
Culture exists in a constant state of change.
Culture includes patterns of both subjective and
objective components of human behavior.
Copied : Clinical Manual for Cultural Psychiatry by Dr. Lim, 2006
DSM-IV-TR Outline for Cultural
Formulation
•Cultural identity of the individual
•Cultural factors related to psychosocial
environment and levels of functioning
•Cultural elements of the relationship between
the individual and the clinician
•Overall cultural assessment for diagnosis and
care
Migration History
Pre-migration history
Country of origin, education, socioeconomic
status, community and family support, political
issues, war, trauma
Experience of migration
Migrant vs. refugee: Why did they leave?
Who was left behind? Who paid for their trip?
Means of escape, trauma
Migration History
Degree of loss
Loss of immediate family members, relatives,
and friends.Material losses: business, careers,
properties. Loss of cultural milieu, community,
religious, and spiritual support
Work and financial history
Original line of work, current occupation,
socioeconomic status
Migration History
Medical history
Beliefs in herbal medicine, somatic complaints
Family’s concept of illness
What do family members think the problem is?
Its cause? What do they do for help?
What result is expected?
Migration History
Level of acculturation
First or second generation
Impact on development
Level of adjustment, assess developmental
tasks