Integrating Cultural Competency in the Delivery of Mental Health Services to Latinos, Challenges and Opportunities: A Social Work Perspective Jacqueline Richardson-Melecio Diversity Rx Conference Presentation Improving Health Care for a Diverse World March 13, 2013

Cultural Competence is: A defined set of values and principles, and demonstrated behaviors, attitudes and structures that enable employees and leaders to work effectively cross-culturally. Managers need to possess the capacity to: value diversity conduct self-assessment manage the dynamics of difference acquire and institutionalize cultural knowledge adapt to diversity and the cultural contexts of the people they lead incorporate the above in all aspects of policy making, administration, practice, service delivery and involve systematically consumers, key stakeholders and communities.

Purpose of Cultural Competency Cultural competence is an understanding and acceptance of the beliefs, values, and ethics of others as well as the demonstrated skills necessary to work with and serve diverse individuals and groups. This involves an experiential understanding, awareness, and respect for the beliefs, values, and ethics of other cultures and the cross-cultural skills necessary for delivering services and working effectively cross-culturally with diverse individuals and groups.

Culture Communication Rituals Roles Customs Courtesies Language Practices Beliefs Relationships Expected Behaviors Manners of Interacting

The 4 Layers of Diversity

When we discuss Cultural Competency Is it about making our services better Is it about addressing social ills/problems Is the focus on the Ethnic Groups or the Patient Who needs to be part of this change What is the appropriate Pedagogy

The Fundamental Components of Individual Cultural Competency? Self-awareness: cultural lenses, bias, style preferences. Recognition of the impact that each of our cultural lenses has on our job role, communication style, and perceptions. Commitment to learn more about target populations of interest. Development of skills for cross cultural communication, evaluation and feedback on skills integrated into professional development.

The Fundamental Components of Organizational Cultural Competency? Clearly articulated vision by senior leaders regarding the importance of diversity and inclusion to the business of the organization. Climate survey: assess the degree to which individuals and members of groups perceive they are valued, rewarded, and have opportunities for growth. On-going education, mentoring, and evaluation throughout the organization for employees and managers to understand the expectations and skills necessary for developing a culturally competent organization. Expectations and success linked to performance management and evaluation systems in order to promote accountability.

Political Climate Opportunity for Addressing Cultural Competency Surgeon’s Generals Report on Minority Health, 2001 President’s New Freedom Commission of 2003 Congressional Health Care Reform 2009 Practice Standards Affordability Care Act Current Research Studies

Practice Standards CLAS & SAMHSA Standards – Cultural & Linguistically Appropriate Standards from Office of Minority Health, DHHS – Provides a comprehensive overview of the components of a culturally competent health care organization SAMHSA Cultural Competency Standards for Managed Behavioral Health Care Organization – Provides consensus guidelines developed through a multi-ethnic process – Provides Performance Standards for Organizations ( The how to)

NASW - Standards & Indicators Ethics & Values Self-Awareness Cross-cultural Knowledge Cross- cultural Skills Service Delivery Empowerment & Advocacy Diverse Workforce Professional Education Language Diversity Cross Cultural Leadership

Cultural Aspects which impact Mental Health Services Beliefs about Mental Health Services Experiences with accessing MH Services Perceptions which hinder seeking MH Svcs. Family & Other support systems Institutional Barriers to MH Svcs. Recovery vs. Prevention vs. Treatment Focus/ Individual Values & Perceptions

Cultural Aspects Impacting the Therapeutic Relationship Conceptions of Mental Illness Normative Help Seeking Patterns Normative Problem Solving Skills Perceptions of Wellness vs. Illness Expectations of Treatment/ Perceptions of Tx Understanding Individual, Social, Organizational/ Systemic Barriers to Care

A Closer Look at the Latino Consumer There are 44.3 million people of Latino descent in the United States (15% of the total population. Latinos account for 50% of the national population growth and it is expected to grow to million or 24.4% of the US population. ( US Census Bureau 2004)

A Closer Look at one Consumer Group 75% of US Latinos population are immigrants or children of immigrants 45% are foreign born Latino children make up 22% of all children under the age of 18 in the US up from 9% in in 5 children living in US is an immigrant or a child of an immigrant and 62% of these children are Latino.

Hispanic Cultural Considerations Establishing Trust Personal Space – close proximity Familiar Expectations/ Involvement of Family in Care Eye Contact-Lack of eye contact may be a demonstration of respect High Level Communication Higher Level Context / : use of silence, non-confrontational Differential Relationships- hierarchy Problem solving skills and approach differ greatly. Interrelationship between Mental & Physical Issues

Perceptions of Wellness Wellness is described in relation to social relationships. The capacity to meet familial/group obligations as opposed to individual wellness & self sufficiency. (Collectivist) Integration between Mental Health & Physical Health “ Paz” “Tranquilidad” Ability to maintain control of ones emotions through life challenges The ability to push through despite life struggles (Fatalism: God doesn’t give you more than you can handle)

Perceptions and Response to Mental Illness Depression is often seen as a result of life challenges and stressors, not as an illness Use of medications should be reserved for individuals w/ severe mental illness, fear of additions Need to be self-sufficient, strong, ability t o deal w/ one’s problems independently is important Use of alternative care/” Home Remedies” Remedios Caseros”

Perception of Illness Using Example of Depression Key Considerations: Recognizing emotional & somatic expressions of illness Perception of causes to mental illness Example of Depression: Considered a response to specific or long term life experiences such as “loss of a loved one”, “inability to meet familial and financial responsibilities

Immigration Challenges Differences in Reception Changes in Economic Status Transferability of Skills and Education Changes in Social Status Isolation Changes in Traditional Gender Roles Language Skills Ability to participate in social and economic sectors of society

Meeting Information & Training Needs of Practitioners Emphasis the importance of everyone being part of the change Value of diversity from a personal, practitioner responsibility, organizational support, practitioner skill, consumer empowerment perspectives A healthy work environment

Challenges of Communicating Relevancy of Cultural Competency Confusion on Definition Challenges of Operationalizing CC Perception/Questioning Professional Competence Political Correctness Demonstrating Evidence

Focus of Study To identify and address relevant challenges, barriers and opportunities related to the integration and adaptation of cultural competency skills in the delivery of mental health services to Latinos Through and understanding of : – Provider Level Capacity( Skills, Knowledge) – Perception of Relevancy – Perception of Organizational Supports for Culturally Competent Care.

Model Diagram for Study : Cultural Competency in the Delivery of Clinical Services to Latino Populations: Social Worker Capacity and Existing Barriers

Framework for Examining Provider Capacity for Cultural Competency Cultural Awareness- – understanding one’s own culture and cultural beliefs Perception of Relevancy- – understanding and appreciating the importance of culture in the helping process. Cultural Knowledge – – gaining information, education about culturally diverse populations – Understanding the impact of culture in the treatment/service relationship. Cultural Competency/ Skills – – the ability to integrate cultural knowledge in the delivery of effective services to individuals from diverse populations

NASW Cultural Competency Standards (1-10) & Indicators 1.Ethics and Values 2.Self Awareness 3.Cross-Cultural Knowledge 4.Cross-Cultural Skills 5.Service Delivery 6.Empowerment and Advocacy 7.Diverse Workforce 8.Professional Education 9.Language Diversity 10.Cross-Cultural Leadership

Study Hypotheses H1 - Providers who have greater knowledge of Cultural Competency are more likely to integrate cultural competency in the delivery of Services. H2 -Providers who have greater skill ( application of knowledge) of Cultural Competency are more likely to integrate cultural competency in the delivery of Services. H3- Providers who work in agencies where there is organizational support for cultural competency are more likely to perceive relevancy and in turn integrate cultural competency in the delivery of services. H4-Providers who perceive the relevancy of cultural competency in the delivery of services are more likely to demonstrate both knowledge and behaviors which result in culturally competent care. H5-Organizational Support and Provider Capacity impact the prevalence of culturally competent services.

\ Study Pathways: Pending Item Independent Variables: Perceived Knowledge, Perception of Relevance, Opportunity (Individual/Organizational) Dependent Variable: Demonstration of CC Skills in Delivery of Services Perceived Knowledge Self Awareness Knowledge of Latino Culture Perception of Relevance Relevancy of Cultural Competency to Practice Organization Supports/Opportunity Resources & Barriers Dependent Variable Integration of Cultural Competency in Practice (Practitioner Behavior) Independent Variables

Definition of Key Terms Provider Organization Culture Competence Cultural Competence Organizational Supports

Key Variables/ Study Domains The NASW standards and related indicators provide a vehicle for defining and operationalzing the Key study variables. Provider Skills Provider Knowledge Provider Self-Awareness Perception of Relevancy Organization Level Supports/Resources

Sampling Population Participant Criteria: Social Workers ( MSW, LMSW, LCSW) Working in a NYS Agency or Hospital Setting Providing Direct Mental Health Services to Latino Clients Must have provided services to Latino clients within the last two years.

Measures/ Instrument Provider Capacity Survey for Cultural Competency: (PCSCC) To provide a comprehensive quantitative data collection opportunity which focuses on measuring critical domains of culturally competent service delivery This instrument focuses on the assessment of provider perspective on individual and organizational strengths and weaknesses in relation to building capacity for cultural competency. Domains Include: Provider Knowledge and Skills Provider Awareness and Perception of Skills Opportunity for Integrating Knowledge and Skills Resources and Barriers ( Individuals and Organizational Level) Provider Perception of Organizational Supports

The Work Ahead Addressing the fragmentation of our care systems Addressing Stigma Associated w/ Mental Health Addressing Workforce issues - need for linguistically and culturally competent staff Moving from Research to Practice (Evidenced based practice) Dissemination of Information to the field: Building a stronger bridge from research to practice: clinical guidelines Increased accountability and monitoring/ documenting outcomes

Provider Level Inquiry Needs Ethnic Identity Immigration History Acculturation Status Language Skills Support Resources/ Needs Health Literacy Help Seeking Patterns Problem Serving Skills Familial Expectations World views on Health Religious & Spiritual Practices and Believes

Organizational Challenges The important of including both administrators and direct service providers in training/ part of the change Challenges in operationalizing information Cost Integrating CC in the policy, practice, program development areas of an organization Conflicting Demands Management and information systems

Meeting Information & Training Needs of Practitioners Emphasis the importance of everyone being part of the change Value of diversity from a personal, practitioner responsibility, organizational support, practitioner skill, consumer empowerment perspectives A healthy work environment

Questions & Answers Closing Remarks For Follow up Questions Please Contact : Jacqueline Richardson-Melecio