Working with Asian American, Native Hawaiians and Pacific Islanders D.J. Ida NAAPIMHA National Asian American Pacific Islander Mental Health Association

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Working with Asian American, Native
Hawaiians and Pacific IslandersD.J.
IdaNAAPIMHANational Asian American Pacific
Islander Mental Health Association
ENVISION THE POSSIBILITIES How to promote
services and improve access for multicultural
consumers across Virginia October 24th 25th,
2007 Marriott Newport News At City
Center Department of Mental Health, Mental
Retardation and Substance Abuse Services
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Overview

• Who are Asian American, Native Hawaiians
  Pacific Islanders (AANHOPI)
• The need to improve the current behavioral health
  workforce
• Mental Health in the AANHOPI communities
• Myths and realities
• Developing a culturally and linguistically
  competent training program
• Working with an interpreter

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Who are AANHOPI

• 14 million Asian Americans encompasses 30 Asian
  subgroups
• 976,400 Native Hawaiian/ Pacific Islanders 21
  Pacific Islander groups
• They are the fastest growing ethnic minority in
  the country
• Immigrant 64
• 1st Generation 23
• 2nd Generation 8
• 3rd Generation 3
• 4th Generation 2
• 8.7 million The number of U.S. residents who were
  born in Asia. Asian-born residents comprise
  one-fourth of the nation's total foreign-born
  population.

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The need to develop a culturally and
linguistically competent workforce
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Healthcare Disparities Communities of color bear
a disproportionately high burden of disability
from behavioral health disorders (USDHHS, 2001).
The burden cannot be attributable to only a
greater frequency or increased severity in these
populations but rather a lack of quality care,
and in many instances they are the recipients of
poorer quality care. Even when communities of
color receive mental health services, they are
usually of substandard quality and not equal to
that of the white population. Source Institute
of Medicine Unequal Treatment Confronting
Racial and Ethnic Disparities in Health Care
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The current mental health system has neglected
to incorporate, respect or understand the
histories, traditions, beliefs, languages and
value systems of culturally diverse groups.
Misunderstanding and misinterpreting behaviors
have led to tragic consequences, including
inappropriately placing individuals in the
criminal and juvenile justice systems. There is
a need to improve access to quality care that is
culturally competentThe Presidents New Freedom
Commission on Mental Health Achieving the
Promise Transforming Mental Health Care in
America. Final Report, July 2003.
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We dont want a piece of the piewe want a
different pie!Winona LaDuke(Anishinabe)
Makwa DodaemBear Clan
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• Why focus on Workforce Development
• There continues to be a serious lack of trained
  bi-lingual, bi-cultural service providers
• 94 of psychologists, 92 of counselors and 89
  of social workers are white.
  US Dept. of Health and
  Human Services, Center for Mental Health Services
  (2001)s
• Having a Ph.D. or MD does not guarantee that a
  person will be culturally competent
• Being bi-lingual by itself does not qualify a
  person to be clinically competent

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Behavioral Health Workforce of Color(Mental
Health U.S. 2002, SAMHSA)
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Consequences for not having culturally and
linguistically competent workforce

• Inaccurate assessment and misdiagnosis
• Development of inappropriate treatment plan
• Poorer access to care
• Consumers have nothing to access
• Results in poorer outcomes
• Increase in severity of symptoms
• Consumer enters services during crisis
• Inappropriate use of children and others as
  interpreters

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Annapolis Coalition for Workforce Development
Recommendations from Cultural Competency
Subcommittee2006

• Goal Reduce and eliminate disparities in the
  healthcare of communities of color through the
  development of a culturally competent workforce.

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Recommendations 1

• Increase, recruit and retain people of color in
  the workforce which includes the use of
  para-professionals, consumers, family members,
  natural healers and trained interpreters.

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Recommendation 2

• Identify, develop, implement and evaluate
  culturally competent training curricula for
  service providers, consumers, family members, and
  para-professionals, including natural healers and
  interpreters.

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Recommendation 3

• Cultural competency training should be a
  requirement for licensure, certification and use
  of interpreters.

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Recommendation 4

• Appropriate rates of reimbursement will be
  established for use of trained, culturally
  competent para-professionals and interpreters.

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Mental Health of AANHOPI

• Negative impact of the model minority myth that
  AANHOPI have few if any problems
• 88 of AAPIs are either foreign born or have at
  least one foreign born parent has great impact
  on services
• Up to 40 of Southeast Asians suffer from
  depression, 35 from anxiety, and 14 from Post
  Traumatic Stress Disorder, PTSD (Nicholson,
  1997).
• The suicide rate for Asian American females over
  the age of 65 are among the highest in the
  country
• Native Hawaiian youth have significantly higher
  rates of suicide attempts than other adolescents

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• In a report on domestic violence in
  Massachusetts, 39 of the Vietnamese respondents
  and 47 of Cambodian respondents reported that
  they know a woman who has been physically abused
  or injured by her partner20 in Hawaii.
• Asian Americans were less likely than white
  patients to report that they were very satisfied
  with their care overall (42 vs. 64), and less
  likely to have a great deal of trust in their
  doctor (55 vs. 71). (commonwealth fund
• AAPIs have the lowest rate of mental health care
  use among all populations, regardless of gender,
  age, and geographical location

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AAPI Beliefs on the Causality of Mental Illness

• Character Weakness
• Bad Luck/Misfortune
• Imbalance of Humors, yin and yang and/or
  disharmony in flow of Chi
• Religious/Spiritual Beliefs
• Loss of faith
• Karma payback for things done wrong in past

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Traditional HawaiianTypes of Illnesses J.
Keaweaimoku Kaholokula

• Mai kino (body sickness)
• Illnesses not caused by the gods, spirits, or
  people.
• Mai mai waho (sickness from outside)
• Illnesses caused by others outside of the ohana.
• E.g., curses and sorcery.
• Mai ma loko (sickness from within)
• Illnesses caused by hukihuki (disagreements) and
  hihia (trouble) within the family.

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Traditional Hawaiian values J. Keaweaimoku
Kaholokula

• Lokahi (unity, agreement, accord, harmony).
• Mana (inner life force)
• Malama (interdependence and interrelated
  nurturing and caring)
• Kuauhau (lineage)
• Huikala (to absolve entirely)
• Laulima (cooperation)
• Hanohano (dignity, pride)

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Cultural values social factors impacting
Mental Health

• Group vs. individual orientation
• Sense of collective responsibility
• Myth of model minority
• Intergenerational conflict
• Cultural and language isolation
• Stressors associated with immigration and
  acculturation

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Why AANHOPI do not seek care

• Stigma and shame
• Knowing vs accepting
• Knowing vs understanding
• Lack of available culturally/linguistically
  competent services
• Lack of awareness of symptoms
• Lack of support to seek services
• Hours of services
• Negative experience in the past

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Developing a culturally and linguistically
competent Workforce
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Questions asked in developing curriculum

• How long does it take to be culturally competent
• How much can be taught in a year
• how in-depth should/can you go in each
  subpopulation
• Who should be focus of training
• interns
• professionals
• para-professionals
• health care workers
• consumers
• Who should be focus of curriculum content
• children/youth/families
• adults
• elders
• specific ethnic population

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More questions

• What are the needs of target population
• How was data collected
• Who will receive services
• Age, ethnicity, language needs, geographical
  region
• Who will receive training professionals,
  paraprofessionals
• Who will provide training
• How culturally competent can a person become in X
  amount of time
• How long does it take to be culturally competent

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Identify target population

• Consumers age, ethnicity, language,
• geographical
  location
• Service providers psychiatrists,
  psychologist, social
• workers,
  physicians, paraprofessional,
• educators,
  law enforcement, etc.
• Supervisors must be trained cultural
  competency
• Interpreters must be trained to work in
  mental
• health setting
• Managers/Administrators understanding
  systems
• issues and
  have buy in from top

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CautionImportant to know about specific
cultural dynamics but critical to stay away from
simplistic solutions e.g. when you see a Chinese
do this
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Challenges impasses that need to be
addressedin workforce training
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Challenges faced by Consumers

• Stigma, shame
• Lack of support to receive services
• Lack of culturally/linguistically appropriate
  services
• Previous experience not positive
• Lack of awareness of services
• Time, location of services
• Having to negotiate multiple systems
• Lack of daycare, transportation

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Challenges for Service Provider

• Not feel competent therefore hesitates to engage
  consumer
• Feel too confident not know limits of
  competence
• Not have language skills nor access to trained
  interpreter
• If from community both positive and negative
• Lack of appropriate supervision
• Not recognize necessity to be culturally
  competent nor respecting importance of diversity
  
• Seeing everyone as the same
• Treating everyone with same level of respect is
  not the same as treating everyone the same

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Challenges for Supervisors

• Getting proper training
• Understanding multiple cultures of consumers
• Understanding culture of service provider
• Lack of awareness of their own cultural biases
• Not understand multiple layers of cultural
  dynamics between consumer/service provider/self
• Intra-ethnic dynamics
• Inter-ethnic dynamics

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Challenges at the Systems level

• Lack of resources to hire, support, maintain
  qualified staff
• Getting reimbursed
• Use of interpreters
• Use of para-professionals who do bulk of work
• Geographical distances
• Dealing with fragmented service delivery system
• Policies, legislation, reduced funding
• Lack of data to support funding requests

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Gathering the data

• Data can help inform..but it must be accurate
• Who identifies what is to be collected
• Who collects the data
• How/where is data collected
• Garbage in

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Old Chinese Saying 1

• No Outcome.
• No income!!!

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Old Chinese Saying 2

• No income
• No outcome!!!!!

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Asian Counseling and Referral Services
Seattle, WA Asian Pacific Development Center
Denver, ColoradoHale Nau Pono
Waeanae, HawaiiHamilton Madison House
New York, New YorkRAMS, Inc. San
Francisco, CaliforniaSan Francisco General
San Francisco, California
NAAPIMHAS Workforce Training Funded by the U.S.
Dept of HHS, Center for Mental Health Services
CMHS
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Growing Our OwnDeveloped with funds from the US
DHHS, SAMHSA Center for Mental Health Services

• Module 1 Know yourself
• Module 2 Connecting with the client
• Module 3 Culturally appropriate
  assessment and diagnosis
• Module 4 Culturally responsive intervention
• Module 5 System cultural competence

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Module ISelf Assessment

• Explore personal beliefs about AANHOPI
• What are personal beliefs about being service
  provider
• How aware are you of your own cultural values
• Assess comfort level of working with individuals
  who are same/different
• Understand own blind spots

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Module IIConnecting with the consumer

• Awareness of persons culture
• Comfort/competence in using interpreter
• Understanding different world views
• High context vs low context communication styles
• Understanding non-verbal cues
• Comfort level with difficult issues

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What was helpful on your road to recovery?

• What was helpful on road to recovery
• Caring
• Made person feel respected
• Understood culture
• Familiar with community
• Able to speak language
• Not make them feel ashamed
• Listened
• Helped with advance directives
• Made them feel better, not crazy

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Module IIICulturally appropriate assessment and
diagnosis

• Get accurate information
• Ethnicity
• American born vs foreign born
• Immigrant or refugee
• Primary language spoken
• Trauma history
• Understand impact of immigration
• Understand impact of culture and language
• Understand cultural definitions of
  health/pathology
• Understand role in family birth order
• Intergenerational conflict
• Impact of racism, colonization

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DSM-IV Outline for Cultural Formulation

• Inquire about consumers cultural identity.
• Explore possible cultural explanations of the
  illness.
• Consider cultural factors related to the
  psychosocial environment
• Critically examine cultural elements in the
  consumer-clinician relationship
• Render an overall cultural assessment for
  diagnosis and care.
• Source Diagnostic and Statistical Manual of
  Mental Health Disorders (4th ed.) (2000).
  Washington, D.C. American Psychiatric
  Association.

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Consumer Centered Assessment

• The following questions provide a framework to
  assist clinicians in recognizing consumers
  perspectives.
• What do you think has caused your mental health
  concerns?
• Why do you think it started when it did?
• What do you think your mental health concern does
  to you?
• How severe do you consider the problem?
• How has your mental health concern changed over
  the past week/month/year?

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Module IVDeveloping appropriate treatment plan

• May include traditional healing practices
• Assess all aspects of persons needs, including
  housing, employment, language needs, support
  services, e.g. transportation, day care
• Assess needs of entire family
• Look at community resources
• If language is an issue, may need interpreter

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Module VCulturally Appropriate System

• Agency must value use of culturally and
  linguistically competent service providers
• Need to have appropriate resources to provide
  training and ongoing support
• Must have adequate reimbursement for services and
  adjunct services
• Look at policies that impact mental health of
  individual, e.g. immigration, English only

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Core Competencies

• Able to do critical self assessment
• Able to do cultural formulation that results in
  appropriate assessment, diagnosis and treatment
  plan
• Able to develop rapport with client
• Good communication skills
• Appropriate use of interpreter
• Ability to work with family members
• Involve client/family in development of treatment
  plan
• Able to negotiate system

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Use of Interpreters

• Gold Standard Use trained, bi-lingual,
  bi-cultural service provider!!!
• Increases rapport with individual
• Facilities communication
• Reduces discomfort and feelings of shame
• Reduces number of individuals in sessions
• Is most sensitive and respectful way to interact
  with individual

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Service provider must be culturally competent!

• Being culturally competent is responsibility of
  provider.
• If clinicians is culturally incompetent
  interpreting insensitive information only
  guarantees incompetence in two languages!

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Identify appropriate language

• This includes knowing proper dialect. Critical
  information may not be translated properly if
  using wrong dialect
• Ask what language person speaks, not where they
  are from as this may be different
• Emotions/difficult concepts are usually best
  expressed in native language

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Use trained interpreter

• If not properly trained, interpreter may give
  inaccurate information
• Even if person appears to be fluent in English,
  technical information and terminology may not be
  understood and accurately translated
• Needs to be familiar with mental health
  terminology
• Must be sensitive to implications of culture and
  how this impacts on individual's response
• If not properly trained may withhold information
  if he/she feels it is "shameful" or damaging to
  client

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Never use child as interpreter

• This places the parent in lower status position
  which results in loss of face
• This places the child in an emotionally difficult
  position of taking care of the parent
• May be asking child to communicate information
  which is beyond his/her developmental
  capabilities, leading to feelings of incompetence

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• Information may not be accurately translated
• May be asking child to divulge family secrets
  which jeopardizes his/her relationship within the
  family
• Child may not wish to share information but feel
  compelled since person asking is in position of
  authority

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Helpful hints

• Address comments to the individual not only is
  this a sign of respect, the person may actually
  understand more than he/she conveys
• Do not direct comments to interpreter this
  ignores the individual and makes him/her feel
  discounted
• Allow interpreter to use cultural norms in
  conveying message, communication styles

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• Speak slowly and allow interpreter to translate
  every few sentences
• Ask for clarification to make sure information is
  conveyed and received accurately
• Do not assume if person nods in agreement or says
  yes that he/she understands what was said
• Own problem of communication - do not blame
  person.

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• Clarify if person understands what has been said
• Review proceedings with interpreter in advance so
  he/she is familiar with your expectations of
  interview, evaluation, etc.
• Debrief with interpreter to see if there is
  information that needs to be clarified or may
  have been communicated non-verbally by
  individual.

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D.J. Ida, Ph.D.Executive DirectorNAAPIMHANatio
nal Asian American Pacific Islander Mental Health
Association1215 19th St. Suite ADenver,
Colorado 80202303-298-7910djida_at_naapimha.org
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Ichigo Ichiye