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Wicked Problems and Collective Solutions: Addressing Disparities

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Title: Wicked Problems and Collective Solutions: Addressing Disparities


1
Wicked Problems and Collective Solutions
Addressing Disparities
  • Larke Nahme Huang, Ph.D.
  • Senior Advisor on Children
  • Office of the Administrator
  • Substance Abuse and Mental Health Services
    Administration
  • Building on Family Strengths
  • Research and Services in Support of Children and
    Their Families
  • Portland Research and Training Center on Family
    Support and Childrens Mental Health
  • Annual Conference
  • May 31, 2007

2
Overview
  • Stories
  • The Demographic Imperative
  • Key Findings from National Data
  • Wicked Problems
  • A Network Structure

3
Stories. in search of happier endings
4
The ChangsCultural Linguistic Barriers to
Negotiating the System
  • In Los Angeles, Mr. and Mrs. Changs young adult
    daughter was removed from the home by the police
    when summoned by a neighbor. She had a serious
    emotional disorder with disruptive behaviors that
    the Changs tried to contain within their home,
    not seeking any help.
  • With limited English proficiency, they searched
    through all the hospitals in the city trying to
    find her due to privacy regulations, hospitals
    were not allowed to tell them if she had been
    admitted.
  • They searched for two weeks before they were told
    to file a missing persons report with the police
    to help locate her.

5
Intoxicado, a 71 million wordLanguage Access
And Availability
  • Recently, a Florida hospital was ordered to pay
    71 million in a malpractice suit that left an 18
    year old a quadriplegic, due to the wrong
    interpretation of the word, intoxicadothe
    paramedics took it to mean intoxicated and the
    translation and intended meaning was nauseated.
    Consequently the wrong treatment was given,
    causing the quadriplegia (Armas, 2007)
  • A major consequence of a lack of linguistic
    competenceIs this a dramatic example? It may be
    the most costly, but not dramatic, because it
    happens all too often.
  • (Ken Martinez, 2007)

6
Seans Story In Need of Appropriate Provider
Intervention and Education
  • 17 year old gay youthcame out to mother at age
    14
  • Mother had difficulty accepting his sexual
    orientation Sean started acting out, stayed out
    late, arguments with mother, escalating to
    physical conflict, hitting his mother
  • After a fight neighbor called police and Sean
    sent to juvenile detention judge sent him to
    foster care group home
  • Mother came to terms with his homosexuality,
    but could not get him released from foster care
  • Agency increased pressure on Sean to change his
    sexual orientation and restricted contact with
    his mother Sean became depressed
  • New probation officer released him to mother
    after 18 months in foster care at cost of 85,000
  • (Caitlin Ryan, 2007)

7
Mrs. Moua Incomplete Information and Dangers of
Misdiagnosis
  • A Denver social services agency following up on a
    complaint of possible child abuse by a Hmong
    mother of 5 children.
  • We conducted a home visit to follow-up on this
    allegation.
  • Was this an abusive mother?
  • Or, is what you see not always the true reality?
  • (DJ Ida, 2007)

8
Red Lake Nation A Dangerous Lack of Resources
  • Visit to Red Lake Nation trauma and suicide
    clusters, the aftermath of violent school-based
    shooting
  • Serious community concerns about the well-being
    of the children and their fears about returning
    to school
  • A 12 year boy, accused of sexually molesting 2 of
    his younger siblings sent from juvenile
    detention to CF services has nowhere to go
  • Placed in a homeless shelter off the reservation,
    temporarily

9
Seung Hui ChoThe Virginia Tech University
Tragedy and the Imperative of Engagement
  • Seung Hui Cho was a young man with a serious
    emotional disorder.
  • Early warning signs, early unusual behaviors were
    noted, family and friends did not turn to the
    mental health system mental health a taboo topic
    within Korean culture
  • Brought to the attention of mental health clinic
    then a special justice for commitment hearing
    ordered to involuntary outpatient treatment - yet
    engagement did not occur.

10
So, what do we learn from these stories?
  • We have many boundaries to cross
  • Chasm between cultures of our diverse communities
    and our helping/care giving systems
  • In the continuum of helping relationships,
    beginning with information and awareness -
    engagement - delivery of services, supports -
    follow-up, we have not passed Step 1.
  • We need to attach resources and develop
    meaningful partnerships with diverse communities
    to begin to cross these boundaries.

11
WHY IS IT IMPORTANT TO CROSS THESE
BOUNDARIES?THE DEMOGRAPHIC IMPERATIVE
12
Minority Population Tops 100 Million (U.S.
Census Bureau, May 17, 2007)
  • 1 in 3 US Residents is a minority
  • Hispanics largest at 44.3M
  • African Americans passed 40M
  • Asian American 14.9M
  • Native Hawaiian Pacific Islanders reached 1M
  • American Indian/Alaska Native 4.5M
  • Non-Hispanic Whites 198.7M
  • Total US Population 300 M

13
Rates of Change and Implications for Capacity
  • Projected Rate of Increase of Youth of Color from
    1995-2015
  • African American 19
  • American Indian/Alaska Native 17
  • Asian American, Native Hawaiian Pacific
    Islanders 74
  • Hispanic 59
  • Caucasian/White decrease -3

14
Emerging Diverse Populations
  • Gay Lesbian Bisexual Youth
  • Immigrant Populations

15
Risk Factors for Gay, Lesbian Bisexual Youth
  • Higher levels of depression and substance use and
    abuse
  • High rates of victimization (also associated with
    depression and suicidality)
  • School-based victimization
  • 3x more likely threatened with weapon at school
  • 2x more likely to have property damaged at school
  • Nearly 5x more likely to skip school because felt
    unsafe
  • (Ryan and Rivers, 2006)

16
Suicidality and Gay, Lesbian, and Bisexual
Adolescents
  • GLB youth 3x more likely to attempt suicide as
    heterosexual youth
  • Between 48 - 76 have thought of suicide
    (compared to 19-29 in adolescent populations)
  • 29-42 have attempted suicide (compared to 7-13
    in adolescent population)
  • Yet, 84 male and 71 female sexual minority
    adolescents report no suicidality at all.
  • (Russell and Joyner, 2001)

17
GLB Youth of Color
  • Challenges of integrating ethnic cultural
    identity with sexual orientation
  • Lack of acceptance within racial/ethnic community
  • Racism within GLB community
  • Further isolation
  • (Morrison and LHeureux, 2001)

18
Emerging Populations Immigrants
  • Immigrant Households
  • Immigrants comprise 12 of the American
    population, and one million new immigrants arrive
    annually.
  • Today, 88 of Asian American and 58 of Latino
    American children are growing up in immigrant
    households, and potentially at risk of
    intergenerational conflict.

19
Mental Health and Immigrants
  • Immigrants in general appear to have lower rates
    of mental disorders than their US born
    counterparts (50 less in some studies)
  • Second and later generations of immigrants have a
    higher risk for mental disorders than their
    parents
  • Ex The prevalence of alcohol and other drug
    abuse was more than 4 times higher in US born
    individuals of Mexican descent than those born in
    Mexico (Vega, Kolody, Aguilar-Glaxiola, Alderate,
    Catalana, Carveo-Anduaga, 1998)
  • (NSAL and NLAAS Studies in the American
    Journal of Public Health, 2007)

20
Mental Health and Immigrants
  • Immigrants increase their risk of mental health
    problems especially if they do not live in native
    ethnic communities.
  • The longer an immigrant family lives in the US,
    the worse their prognosis
  • (National CoMorbidity Replication Study,
    Kessler et al, 2005)

21
12-Month MH Service Use Among Asian Americans By
Generation (Alegria and Takeuchi, 2007 National
Latino and Asian American Study/ NIMHSAMHSA)
22
Perceived Helpfulness of Care by Nativity
(Alegria Takeuchi, 2007)
23
Perceived Helpfulness of Care by Generation
(Alegria Takeuchi, 2007)
24
Dual Pathways to Care for Youth of Color
25
The Criminalization Of Youth Of Color
(Disproportionality)
  • Estimated that 50-75 of youth in detention have
    emotional behavioral disorder
  • 73 reported MH problems during screening 57
    previously received MH treatment 55 symptoms of
    depression 50 conduct disorders 50 with MH
    disorder had substance abuse disorder
  • The national juvenile justice custody rate for
    youth of color to that for Caucasians was 2.6 to
    1 in 2003
  • In 2003, 59,000 youth of color were locked in
    juvenile facilities 61 of total youth in
    custody while they are 1/3 of youth population
  • Children and youth of color are being locked up
    at a disproportionate rate and are not being
    treated in the community or in jail
  • (Coalition on Juvenile
    Justice, 2000 Snyder, Howard and Sickmund, 2006
    Martinez, 2007)

26
Youth of Color in the Child Welfare System
  • Disproportionate 42 of youth are children of
    color in the U.S. yet, 57 in foster care are
    youth of color
  • African American children 15 of children in CW,
    but 28 of substantiated allegations of abuse and
    34 of foster care population
  • Blacks, Hispanics and Asian/Pacific Islander have
    disproportionate rate of maltx investigations
  • African Americans15 of total population under
    18, yet 40 of foster care population
  • Uneven treatment at different points in CW system
  • Fewer services, plans for family contact, family
    services, and less contact with CW staff
  • Placed in out-of-home placement more frequently
    and for longer periods of time.
  • (Census Data, 2004, and CWLA,
    2007)

27
What does national data tell us about mental
health and substance use issues for diverse youth?
28
Major Depressive Episode (MDE) in the Past Year
among Youths Aged 12 to 17, by Race/Ethnicity
2004-2005 (SAMHSA/National Household Survey on
Drug Use and Health NSDUH- 2006)
29
Had at Least One Major Depressive Episode (MDE)
in Lifetime and Receipt of Treatment in the Past
Year for Depression among Persons Aged 12 to 17
by Race/Ethnicity Percentages 2005 (NSDUH)
30
Had at Least One Major Depressive Episode (MDE)
in Past Year and Receipt of Treatment in the Past
Year for Depression among Persons Aged 12 to 17
by Race/Ethnicity Percentages 2005 (NSDUH)
31
Percentages of Youths Aged 12 to 17 Receiving
Alcohol Use Treatment in the Past Year among
Those Who Were Classified as Needing Alcohol
Treatment in the Past Year, by Demographic
Characteristics 2003 and 2004 (NSDUH)
32
Percentages of Youths Aged 12 to 17 Receiving
Illicit Drug Use Treatment in the Past Year among
Those Who Were Classified as Needing Illicit Drug
Treatment in the Past Year, by Demographic
Characteristics 2003 and 2004 (NSDUH)
33
Key Findings
  • Variable patterns of major depressive episodes
    and illicit substance abuse among diverse youth
  • In all situations, multi-racial youth have among
    the highest rates of MDE and SA
  • Significant disparity between need for and
    service utilization across all groups
  • Very substantial gap in need and service use
    among American Indians

34
What do we know about co-occurring disorders and
response to interventions among diverse youth?
35
Change in Substance Use Problems Over Time by
Race/Ethnicity Level of Care
Regular Outpatient
Intensive Outpatient
36
Change in Substance Use Problems Over Time by
Race/Ethnicity LOC
Short-Term Residential
Long-Term Residential
37
Preliminary Conclusions
  • Racial/ethnic disparities in treatment outcomes
    exist
  • Treatment related changes vary by race/ethnicity
    and level of care
  • Racial/ethnic disparities are complex --
    different patterns by outcome and by subgroups
    within race/ethnicity
  • Over time treatment effects vary by race/ethnicity

38
What About Co-occuring MH and SU Disorders for
Diverse Youth?
  • A significant proportion of youth with substance
    use disorders also have co-occurring mental
    health problems
  • Although it is unclear which problem predates the
    other, it is clearly recognized that the success
    of treatment depends on the degree to which both
    problems are effectively addressed
  • It is also known that there are significant
    racial/ethnic variations in the patterns of
    substance use and co-occurring mental disorders,
    and in access to and outcomes of treatment

39
For Youth in SA Treatment, do overall levels of
internalizing symptoms vary by race/ethnicity?
  • Internalizing symptoms depression, anxiety,
    traumatic disorders, suicidality
  • Preliminary Findings
  • African American youth had lower levels of
    internalizing symptoms than White or Hispanic
    youth
  • Dx rates were also lower for African Americans

40
Rates of Major Depression Over Time
41
Rates of Major Generalized Anxiety Disorder Over
Time
42
Rates of Major Suicidal Problems Over Time
43
Research Questions(M. Mulatu and K. Jeffries
Leonard, 2007-Joint Meeting on Adolescent
Treatment Effectiveness, Washington, DC)
  • Are there racial/ethnic differences in the degree
    to which substance abuse treatment affects levels
    of co-occurring disorders?
  • Can race/ethnic disparities, if any, be
    attributed to differences in levels of care?

44
Do different types of treatment show different
results for diverse youth?
45
Patterns of Changes in Internalizing Symptoms by
Race/Ethnicity and Level of Care
Regular OP
Intensive OP
46
Patterns of Changes in Internalizing Symptoms by
Race/Ethnicity and Level of Care
Medium-Term Residential
Long-Term Residential
47
So, what is our response?
48
National Policy Statements and Presidential
Commissions
  • The Surgeon Generals Report
  • Mental Health Culture, Race and Ethnicity (2001)
  • The Institute of Medicine Report
  • Unequal Treatment Confronting Racial Ethnic
    Disparities in Health Care (2002)
  • The Presidents New Freedom Commission Report
  • Achieving the Promise Transforming Mental
    Health Care in America (2003)
  • National momentum for addressing
  • disparities in behavioral health care
  • proclaim public health imperative

49
Political Will Collective Will
  • States
  • New Jersey Law requires NJ physicians to take
    cultural competency training to obtain a medical
    license
  • Connecticut setting benchmarks for cultural
    competence
  • California, Mass, Oregon, Utah state plans for
    cultural competency
  • National Organizations
  • National Alliance of Multi-Ethnic Behavioral
    Health Associations
  • First Nations, NAAPIMHA, NLBHA, NLC
  • System Penetration
  • Penetration into more child-serving systems
  • JJ Disproportionate Minority Confinement
    Equal Justice Initiative
  • Penetration into low-capacity, newly emerging
    population areas
  • Mental Health Specialty Provider Networks
    (Minnesota)

50
Published Research and Reports on
  • Ethnic Minority Mental Health
  • Clinical Care with diverse populations
  • Cultural Competence
  • Risk and Protective Factors for diverse
    communities
  • Some, Limited Treatment Effectiveness Studies for
    Diverse Populations
  • Child and Youth Development research different
    models of development, including ecological
    approached

51
What else do we know?
  • In the field, abundance of community practices
    that have worked for diverse groups of
    children, youth, families and adults.
  • Culturally-based interventions and approaches
    that are less frequently studied and documented
    (e.g., engagement strategies, cultural brokers,
    promotoras, primary care integration, village
    models, housing project-based care, newcomer
    centers, etc.)
  • See focal point Summer 2007

52
Status update?
  • We know more than we know
  • We share less than we could
  • We reinvent, reinvent, reinvent
  • We discover the discovered

53
Mental health and substance use disparities are
wicked problems
  • Highly complex, intractable social problems
  • Messy problems that defy precise definition, cut
    across policy and service areas
  • Multiple contributing factors poverty, language
    barriers, structural racism
  • Resist solutions offered by the single-agency or
    silo approach
  • Traditional ways of working add to the problem by
    further fragmenting services and people

54
Network Structure as a Strategy to Address
Wicked Problems
  • Require new ways of working and thinking beyond
    traditional approaches
  • Concept of network structure to identify,
    collect, develop innovative solutions for
    communities
  • Network structures people actively work together
    to accomplish what they recognize is mutual
    concern

55
3 Characteristics of Network Structures
  • 1. Common Mission
  • Requires
  • seeing the whole picture
  • new values, new attitudes
  • Expected Outcomes
  • Each member see self as one piece of total issue
  • See points of convergence, not contention
  • Not fighting over scarce resources
  • Not wasting time and money

56
Characteristics of Network Structures
  • 2. Members are interdependent
  • Requires
  • Step into others shoes
  • It is not what you expect from others, but how
    you understand them
  • Expected Outcomes
  • Building relationships is primary, tasks are
    secondary
  • Connecting existing pockets of trust
  • Building trust
  • Recognizing expertise of others
  • Listening/valuing community experts

57
Characteristics of Network Structures
  • 3. Unique structural arrangement
  • Composition reps of diverse organizations,
    groups, government, business, community, etc.
  • Requires
  • Actively doing something
  • Members represent own organization and the
    network structure
  • Expected Outcomes
  • Risk taking proactive
  • Innovative ideas emerge
  • Visible/invisible conflicts

58
Networks vs Network Structure
  • Beyond networking people making connections
    thru meetings and communication technology
  • Networks - links among organizations or
    individuals become formalized
  • But still working separately

59
Leadership in Network Structures
  • Atypical forms of power and authority
  • Informal power based on interpersonal relations
    can be more important than formal power
  • Modes of leadership rely on role of facilitator
    and broker
  • No one in charge
  • Rely on exchanges based on interpersonal
    relations rather than contractual arrangements
  • Pockets of trust exist before network structure
    is formed
  • Success of network structure based on the
    collective orientation
  • Culturally different form of leadership and
    authority- soft rather than hard power

60
  • National Network to Eliminate Disparities in
    Behavioral Health Care
  • Community and Ethnic-Based Organizations and
    Networks
  • Knowledge Discovery Centers
  • National Facilitating Center

61
National Network to Eliminate Disparities in
Behavioral Health Care (NNED)
Vision All culturally, racially, ethnically
diverse individuals and families live healthy,
thriving lives in supportive communities (draft).
Mission To build and sustain a national
network of diverse racial, ethnic and cultural
communities and organizations to promote
policies, practices, standards and research to
eliminate behavioral health disparities.
62
National Network to Eliminate Disparities in
Behavioral Health CareA SAMHSA-Supported
Initiative
  • Key Assumptions
  • Around the country, there are pockets of
    excellence in reducing disparities
  • There is a wealth of information, insights and
    knowledge that is not be shared
  • Research and policy efforts often lack the
    connection to and depth of involvement of the
    very communities they seek to serve
  • Lack of coordination of information stymies
    forward movement

63
DESIRED OUTCOMES
  • LINKAGES between community providers,
    organizations and networks in diverse communities
    and research/training centers
  • IDENTIFY AND LINK POCKETS OF EXCELLENCE
  • INFRASTRUCTURE for collecting, analyzing and
    disseminating information, best practice,
    research and policy
  • CAPACITY BUILDING through learning
    collaboratives, internet training strategies, and
    community action
  • TARGETED ACTIONS through community collaboratives
    to impact disparities

64
DESIRED OUTCOMES
  • NATIONAL INFLUENCE to focus on elimination of
    disparities
  • COORDINATED RESPONSES for recommended policy,
    practice and research direction to the field
  • COMMUNITY SYSTEM CHANGE through changes in
    knowledge, attitudes, behaviors of individuals
  • BEHAVIORAL HEALTH DISPARITY ELIMINATION to ensure
    access to and availability of culturally
    appropriate, high quality, results-producing
    care.

65
National Network to Eliminate Disparities in
Behavioral Health Care
STRUCTURE
The NNED structure consists of three interlocking
entities.
Community and Ethnic-Based Organizations and
Networks
Knowledge Discovery Centers
National Facilitating Center
66
National Network to Eliminate Disparities in
Behavioral Health Care
STRUCTURE
  • Define and document problems and solutions
  • Promote new perspectives
  • Exchange and share information peer to peer
    technical assistance
  • Create opportunities for community partner
    involvement

Community and Ethnic-Based Organizations
Networks
67
National Network to Eliminate Disparities in
Behavioral Health Care
STRUCTURE
  • Redevelop frameworks for research on disparities
  • Research community-defined best practices
  • Provide TA and consultation
  • Support a community of learners
  • Engage communities in partnership

Knowledge Discovery Centers
68
National Network to Eliminate Disparities in
Behavioral Health Care
STRUCTURE
  • Develop and maintain a network infrastructure
  • Identify and link entities
  • Share information and disseminate knowledge
  • Coordinate, track, monitor NNED projects
  • Implement NNED communication strategy
  • Provide TA/Training Vehicles
  • Website
  • Develop/Implement Funding Plan

National Facilitating Center
69
Priority Areas
National Network to Eliminate Disparities in
Behavioral Health Care
  • Community-defined Evidence Models to Measure
    Practice Effectiveness (inventory of effective,
    community-based practices criteria for
    community-defined evidence, etc.)
  • Anti-Stigma and Behavioral Health Education
    Campaigns for Diverse Groups (Ad Council and
    diverse community leaders to develop culturally
    appropriate messages and vehicles and strategies
    for better reaching diverse communities)
  • Community Engagement Models
  • Workforce Development
  • Integration of Health/Behavioral Health

70
Pockets of Excellence to disseminate and
promote uptake
  • Re-arraying Services
  • Community Engagement Community Health Care
    Workers
  • Asian Counseling and Referral Services The
    Village Project
  • Systems Change
  • Child Welfare Disparity Reduction
  • Juvenile Justice Reducing Disproportionate
    Minority Confinement

71
And more..
  • Child Family Interventions
  • Indian Country Trauma Center Cultural
    Adaptations of Interventions
  • Focal Point Effective Interventions for
    Underserved Populations, summer 2007
  • Training and Workforce
  • HBCU Coordinating Center at Morehouse University
    workforce training
  • And on and on..

72
A Health Example Tuberculosis Community-based,
Cultural Case Manager Model
(Chaulk, 2004)
  • Builds on the local knowledge of the target
    neighborhood.
  • Views cultural competence as not just skin color
    or language fluency
  • Interpreters as mediators most effective.
  • Relies on Neighborhood Health Messengerstrusted
    , credible people from the communitywho can
    translate information into and out of the
    neighborhood (two-way flow of information) and
    help bridge the worlds of vulnerable families and
    public systems
  • Incorporates team orientation with communities
    and community residents--not just doctors and
    nurses seen as experts.

73
Traditional TB Clinic Model
TB Clinic
TB Clinic
TB Clinic
Client
Client
Client
At 3 Months
At 6 Months
At 9 Months
Intensity of Social Networks
Primary care
Housing
Primary care
Primary care
TB Clinic
TB Clinic
Social
TB Clinic
Social
Social
Phone 48
Client
Client
Trans.
Client
Phone 72
Housing
Work
School
Phone 24
Housing
6 home visits
3 home visits
9 home visits
School
School
Housing
Cultural Case Manager Model
74
Therapy completion rates (96-98 vs. 99-01)
N 319
75
Therapy acceptance rates (96-98 vs. 99-01)
N 389
76
Ex Disparity Reduction for Children of Color in
Child Welfare (Redd, Bell, et al, 2005)
  • Reducing the number of African American Children
    in Child Welfare in 2 cities in Illinois removal
    of child from home.
  • Removal rate in two counties 24/1000 and
    23/1000 overall rate of removal was 4.3/1,000
  • Strategy combine business principles with
    cutting edge behavioral intervention research
  • Implemented
  • Assessment of service environment contextual
    factors
  • Develop sound business plan that includes QA, use
    of data, analysis of decision-making points
  • Improve quality of existing services
  • Introduce new community-based leadership group
  • 3rd Year of Intervention Base rates for removal
    of African American youth had decreased by more
    than 50 (from 24/1000 to 11/1000)

77
Targeting Disproportionality in Juvenile Justice
(Burns Institute Casey Foundation, JDAI,
2002)
  • Juvenile Detention Alternatives Initiative
    communities develop alternatives to detention
    without jeopardizing safety of community
  • Risk Assessment Instrument remove bias
  • Obtain data at every step of the way ? pinpoints
    what actions are considered, identify where along
    continuum of care that disparate decisions were
    being made ? discuss with staff
  • Review decisions of intake staff by looking at
    disposition rates for diverse youth feedback to
    staff

78
Targeting Disproportionality in Juvenile Justice
Results
  • Once we had real data, we were able to move from
    anecdotal information to data-based strategies,
    because now we knew how real the problem was
    Judge Bergman
  • Results
  • Gap between white and youth of color in
    likelihood of being detained decreased
  • For African American and Latino youth number
    admitted to detention dropped by half.

79
Results Proportion of Delinquency Referrals
Resulting in Detention by Race/Ethnicity

(Casey, JDAI, 2002)
80
Integration Co-Location of Mental Health and
Primary Care
  • Primary Care Centers
  • HRSA Community Collaboratives
  • Depression Collaborative
  • Family Resource Centers
  • Westchester Family Health Centers Latino mental
    health screening
  • Urban Mental Health Initiatives Richmond, Miami
  • Community Resource Centers
  • Asian Counseling Referral Center Village
    Project
  • School-based Health Centers
  • Dallas School-based clinics improved outreach
    and care to students of color
  • Native American youth engage in interventions
    for substance use and suicide prevention when
    offered in schools and provided to all students,
    minimizing stigmatization of at-risk youth

81
Culturally-Based Behavioral Health Interventions
  • The Miami Group Szapocznik Collaborators
  • 3 decades work with poor, inner city Hispanic and
    African American families
  • Adapted and further developed interventions based
    on cultural values (structural and strategic
    family therapy)
  • Keep refining interventions to population needs
    and changing cultural context
  • Studies to examine generalizability to other
    ethnic groups
  • Developed empirically supported treatments using
    ethnic minority groups
  • Ongoing work design flexible manuals to tailor
    interventions to specific life situations,
    culture-related stressors
  • (Bernal, G., 2006 Muir, Schwartz Szapocznik,
    2004)

82
Cultural Adaptations to Behavioral Health
Interventions Cognitive Behavioral Therapy
  • Modifying concepts thought stoppage vs. leave
    bad thoughts at the door (Native American
    adaptation)
  • School-based CBT for anxiety in low-income
    African American teens in manualized protocol
    included experiences that these teens would
    encounter, neighborhood crime, violence, issues
    related to kinship care decreased anxiety
    symptoms (Ginsburg Drake, 2002)
  • Evidence that culturally sensitive CBT can be
    successful with youth from diverse backgrounds
    for treatment of depression and anxiety (Mirande
    et al, 2005)

83
Cultural Adaptations to Behavioral Health
Interventions Parent-Child Interaction Therapy
  • Parent Child Interaction Therapy (PCIT)
  • Oklahoma Group Delores BigFoot, Indian Country
    Child Trauma Center (2006)
  • Aligning Native American cultural values re
    honoring children and importance of relationships
    (attachment theory)
  • Modifying concepts and terms
  • San Diego Kristin McCabe et al (2004)
  • Reframe intervention as educational vs.
    therapeutic
  • Teacher/expert vs. therapist
  • Comprehensive engagement protocol incorporate
    extended family members, removal of barriers to
    treatment

84
SAMHSA Cultural Competence and Disparities
Roadmap
  • CCED Matrix Work Group internal and external
    processes
  • External Activities
  • Public Education and Information Campaign
    Tailored for 4 Racial Ethnic Communities
  • Workshops and Town Halls American Indian/
    Native Hawaiian and Pacific Islanders
  • Support of the NNED
  • Internal Activities
  • Examination of Grants Solicitation and Review
    Process (e.g. Tribal input)
  • Inventory of CCED-focused projects, products and
    initiatives
  • Internal Professional Development and Training on
    CCED
  • Better coordination among the 3 Centers and the
    Offices

85
There is hope for, as a collective,
  • We are ready to identify and capitalize on good
    work being done and to support families and youth
    to strengthen their familial, cultural, ethnic,
    racial, linguistic connections so that families
    find solutions and not systems!
  • We are ready to walk in the diverse worlds of
    performance measurement, data for continuous
    quality improvement and accountability and
    ethnographic and personal stories.
  • We are ready to build our community and
    professional relationships in a concerted effort
    to ensure that all children and families have
    hope and opportunity for fulfilling lives in safe
    and supportive communities.

86
Acknowledgements
  • Rosalba Garcia
  • Ken Martinez, PsyD
  • David Takeuchi, Ph.D.
  • Kimberly Jeffries Leonard, Ph.D.
  • Mesfin Mulatu, Ph.D.
  • Beatrice Rouse, Ph.D.
  • DJ Ida, Ph.D.
  • Myia Holmes
  • Caitlin Ryan, Ph.D.
  • PJ Rivera
  • Gail Ritchie, MSW
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