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Culturally and Linguistically Responsive Care for Early Psychosis
Dr. Jorge Ramírez García
April 8, 2020 CLR & Psychosis 2
Northwest Mental Health Technology Transfer Center
Our Role
Provide training and technical assistance (TA) in evidence-based practices (EBP) to behavioral health and primary care
providers, and school and social service staff whose work has the potential to improve behavioral health outcomes for
individuals with or at risk of developing serious mental illness in SAMHSA’s Region 10 (Alaska, Idaho, Oregon, and
Washington).
Our Goals
• Heighten awareness, knowledge, and skills of the workforce addressing the needs of individuals with mental illness.
• Accelerate adoption and implementation of mental health-related EBPs across Region 10.
• Foster alliances among culturally diverse mental health providers, policy makers, family members, and clients.
The MHTTC uses affirming language to promote the promises of recovery
by advancing evidence-based and culturally informed practices.
April 8, 2020 CLR & Psychosis 4
Today’s Trainer
• Jorge Ramírez García, PhD; Research and Evaluation Scientist
at Oregon Research Institute and has held Program and
Research Analyst and Health Equity Coordinator positions at
Greater Oregon Behavioral Health
• Focuses on service programming and research to strengthen family and community care of individuals with psychosis
• Currently serves on the Cultural Competence and Continuing
Education Steering Committee and the Health Equity Committee
of the Oregon Health Authority
RESEARCH SUPPORTED BY
National Institute of Mental Health NRSA Training Grant MH14584 (Psychological Research on Schizophrenic Conditions) &
Paso del Norte Health Foundation
Overview (Objectives)
I. Importance of: Psychosis and Culturally
& Linguistically Responsive (C&LR) Care
II. Need for C&LR Care for Psychosis
III. C&LR Care for Psychosis Illustrations
IV. Implications
I. IMPORTANCE of Psychosis and of
Culturally & Linguistically Responsive Care
PSYCHOSIS +Delusions; hallucinations; disorganized thought -Deficits: Impaired functioning
0%
10%
20%
30%
40%
50%
60%
Risk
Probability of Schizophrenia by Heredity
Pop. At-large 1 Parent Schiz. 2 Parents Schiz.
April 8, 2020 CLR & Psychosis 8
Diathesis-Stress Hypothesis
Schizophrenia
“ENVIRONMENTAL STRESS”
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Risk
Probability of Schizophrenia by Heredity
Pop. At-large 1 Parent Schiz. 2 Parents Schiz.
April 8, 2020 CLR & Psychosis 9
Course of Schizophrenia Model
April 8, 2020 CLR & Psychosis 10
Public Health Importance
• High global burden of disease
Early onset leads to many years with
disability (psychosis) due to impact on
functioning
Higher risk of co-occurring illnesses with
high disease burden
• Shorter life span
Culturally and Linguistically
Responsive Care
Services that are….
• Respectful
• Responsive to individual’s
• Cultural beliefs and practices
• Preferred language(s)
• Health Literacy Levels
• Communication needs
• Employed by all individuals/members of organization
• Regardless of size
• At every point of contact
Culturally and Linguistically Appropriate Service standards (CLAS)
WHY C&LR CARE?
“Business” Case “Humanitarian / Justice” Case
• Reduce health disparities
Ethnic minorities and/or low income
More likely sick
Poor access to quality care
• Improving quality of clinical care
• Better equipped to respond to cultural / ethnic “gaps”
• Equitable = > Social / Distributive Justice
Culturally and Linguistically Appropriate Service standards (CLAS)
• Reduce unnecessary costs due to
avoidable health disparities;
treatment errors (e.g., $230 billion
lost between 2003-2006)
• Regulations (integrity of services)
• Accreditation (e.g., NCQA)
Communication
Cultural competence
Patient-Centered care
Linguistic Assistance
CULTURE COUNTS, CULTURE MATTERS
Defining Culture
CLAS (Office of Minority Health)
Integrated pattern of thoughts, communication, actions, customs, beliefs, and/or values.
Characteristics partly based on …
Racial; Ethnic; Religious; Spiritual; Linguistic; Socio-economic; or Geographic groups
Kral, Ramírez García et al. (2011)
Health Disparities / Inequities
Specific subset of differences
• Health status
• Health care utilization
• Health determinants
That are largely:
• Avoidable
• Due to social determinants of health
• Due to ethnic/cultural determinants of health
Cook et al. (2014)
II. Need for CL&R care for
Psychosis
As long as there are:
a) Disparities / Inequities
b) Cultural and Linguistic determinants of
psychosis …
There is the need for Culturally and
Linguistically Responsive Care
Cultural and Linguistic determinants of Psychosis have discernible differences between groups
In overall levels
In the way that they impact health or other health factors
Disparities/Inequities in Psychosis:
Latina/os, & ethnic minorities
+ be diagnosed with Schizophrenia
+ have poor outcomes in occupation & social functioning
+ disengage from treatment
+ drop out prematurely
- Participate in case management
- Engage in treatment
- Be rehospitalized
More
Lik
ely
to
Less lik
ely to
Maura & Weisman de Mamani (2017)
April 8, 2020 CLR & Psychosis 19
Linguistic Case Study: “Tiene Nervios”
View that Psychosis is a case of “Nervios” [Nerves]
• “Nervousness” or “distress”? • Therefore DX= Anxiety or
Psychological distress
• Therefore RX=tranquilizers; relaxation techniques
(Guarnaccia et al., 1992)
April 8, 2020 CLR & Psychosis 20
Language and Proverbs:
Caregiving for psychosis
• “Locos, locos… pero no tragan fuego” [Mentally ill… How come they don’t eat fire]: Attributions
• “Si Dios Quiere [God Willing]” : Coping
Kuipers et al (2010)
April 8, 2020 CLR & Psychosis 21
31%
40%
69%
9%
LIV. FAMILY LIV. ALONE
Liv. Arrangements Post-Discharge
Europ. Am. (White) Hispanic
8%
71%
40% 42%
EMOTIONAL OVERINV. CRITICISM/HOSTILITY
Expressed Emotion Subtypes
Europ. Am. (White) Hispanic
Latinx Family Caregiving Face I:
(Over)involved & Burdened
Ramírez García et al. (2004) López; Ramírez García et al (2009)
April 8, 2020 CLR & Psychosis 22
Latinx Family Caregiving Face I:
(Over)involved & Burdened
• LATINO CAREGIVER DISTRESS
• (MAGAÑA, RAMÍREZ GARCÍA ET AL. 2007)
• 20 Latino adults
• 15 Latino caregivers
•
April 8, 2020 CLR & Psychosis 23
(Over)involvement & Burden:
Protectors (Hypotheses summary)
Lower Levels
Over Inv. &
Burden
Coping Efficacy
Acceptance (detachment)
Dorian, Ramírez García et al. (2008) Ramírez García et al (2009)
April 8, 2020 CLR & Psychosis 24
Latinx Family Caregiving Face II:
Warm, Supportive, & Recovery Allies
(Hypotheses summary)
Warmth;
High
enculturation
Lower
Psychiatric
Relapse
Coping
Efficacy
Caregiver
Instr. Support
to Patient Family
Level
Support
of CG Religious
Leader
support
of CG
Medication
&
Treatment
Usage
Non-
Blaming
Attributions
Marquez & Ramírez García (2013)
CLR & Psychosis 25
Ramírez García et al. (2006)
Dorian, Ramírez García et al. (2008)
(Lopez et al 2004; Aguilera et al. 2010)
III. Culturally & Linguistically
Responsive Care for Psychosis
Illustrations
Linguistic / Acculturation Spectrum
• LEP – Interpretation & Translation + Cultural Adaptation
• English Speaking – Cultural Adapt.
Limited English Proficiency (LEP)
Immigrant; 1st Gen.
2nd and Later Gen.
April 8, 2020 CLR & Psychosis 27
Culturally & Ling. Resp. Care:
Psychosis + Language & Culture
PSYCHOSIS
Cognitive challenges require information to be:
*Simple
*Bite sized
Limited English Proficiency
* Translation
* Interpretation, or
* Bi-Multilingual staff
Culture
Respond to …
* Behavioral / Linguistic Acculturation
* Values / Attitudes
* Identity
April 8, 2020 CLR & Psychosis 28
Quality
Written Translation
Oral Interpretation
Linguistically Responsive Care
April 8, 2020 CLR & Psychosis 29
Cultural Responsiveness (CR):
Frontline Workers
SKILLS
AWARE:
SELF
CR
AWARE:
FELLOW
AWARENESS OF
• One self
• Fellow human beings (“others”)
SKILLS: • Focused on interaction
(“process”)
• Dynamic; iterative
• Shifting cultural lenses
(Lopez)
• Scientific Mindedness (Sue)
April 8, 2020 CLR & Psychosis 30
Shifting Cultural Lenses & Psychosis
Engagement &
Assessment
Theory Intervention
• Engagement: Establishing a working relationship
• Definition of problem • Helper model
• Theory=Explanatory model of • Person’s functioning • How therapy works
• Intervention = Treatment methods
• Procedures to facilitate behavior change
• Openness to adapt the intervention method to patients’ expectations
April 8, 2020 CLR & Psychosis 31
Lopez et al. 2002
TOOLS & EXAMPLES
(Workforce focused)
CULTURAL RESPONSIVENESS
DOMAIN(S)
Cultural Formulation Interview
(DSM-V; Lewis-Fernandez)
Skills; Assessment; Engagement
Social & Cultural Assessment of
Hispanic Immigrants
(Guarnaccia, 1996)
Assessment: (a) Language; (b) Family
Structure; ( c ) Social supports; (d)
Migration experience; ( e ) Religious
beliefs & Practices; (f) Health Care
utilization
Culturally and Linguistically
Appropriate Services standards
https://thinkculturalhealth.hhs.gov
Targets entire tripartite model; Includes
how to elicit narration of problem.
Check your regional/state
resources
April 8, 2020 CLR & Psychosis 32
Cultural Responsiveness of
Programs
APPROACHES TYPE
Goal:
Optimize Cultural and Linguistic
Responsiveness
Culturally Resp. Program
ADAPT
(Existing Program)
MODIFY:
Surface Structure (Characteristics)
MODIFY:
Deep Structure
(Content “targets”)
DEVELOP
(New Program)
Cultural / Linguistic Elements key foundations
April 8, 2020 CLR & Psychosis 33
Culturally Responsive Programs
& Targets
Culturally Adapted Program examples
Social skills training for Latinos (Liberman &
Kopelowicz, 2009; Kopelowicz, 1998)
Multi-Family Group (Kopelowicz et al., 2012;
2015)
Culturally-Specific (Developed) Program
Examples
Culturally Informed Family Intervention
(Weisman et al., 2014)
Psychosis Health Literacy: Community outreach
– La Clave [The Clue] (Lopez et al. 2018)
Cultural Targets (Maura & Weisman de Mamani, 2017)
Family Involvement
Religious/Spiritual Values
Community Engagement
Stigma
Trust / Confidence in mental health systems
April 8, 2020 CLR & Psychosis 34
Shifting Cultural Lens – Expanded
(La Clave)
COMMUNITY OUTREACH:
+ Increase knowledge of psychosis
+ Efficacy beliefs to identify psychosis
+ Professional help-seeking
• Discern attributions to psychosis
(Lopez et al. 2009)
III. IMPLICATIONS FOR PRACTICE &
RESEARCH
37
(Compton et al. 2011)
Lighthouse: Quality & Rigor
Taxed Workforce
Admin burden
DEI & Other
Trainings
Complexity of Culture
• Optimize value of training & programming (avoid extremes)
• Increase rigor to produce results and garner buy-in from all stakeholders
Integrate Ethnic/Cultural & Social Determinants
of Psychosis (health)
Integrate Ethnic and Social Determinants of Health in
Assessments, Intervention & Research
Braveman et al. (2011)
April 8, 2020 CLR & Psychosis 39
Ethnic & SDOH
Level 1: Individuals
• Social-Cognitive Interpretations
• Health (& Psychosis)
• Identity
• Stress appraisals & Coping
• Norms & Values
• Cultural change
Ramírez Garcia (2019)
April 8, 2020 CLR & Psychosis 40
Ethnic & SDOH
(Psychosis) –
Levels 2 to 4
Social Structures
Built Environment
Relationships & Community
• Education / health literacy
• Vocation/ Occupation
• Living arrangements/Housing
• Segregation / criminalization
• Family / Close relationships
• Social networks
Ramírez Garcia (2019)
Use CLAS and Dissemination & Implementation
Science to promote C&LR Care
Cultural & Linguistic Appropriate Standards
Dissemin. & Implementation Science
Examples of Value
• Importance of Organizational Leadership
• Defining Units of analyses
Chambers & Norton (2016)
Culturally and Linguistically Responsive Care for Early
Psychosis
Questions and Final Remarks
Get in Touch! Visit us online:
www.mhttcnetwork.org/northwest
Find out about:
• Upcoming trainings
• New online trainings
• Resources and Research Updates
Email us:
Follow us on social media:
@NorthwestMHTTC
Thank You!