Oregon has a significant Indochinese minority com- munity. Seen through the eyes of this group, few of the dgiculties minorities encounter when seeking cultur- ally competent services have changed under the Oregon Health Plan.

12

Multicultural Mental Health Services Puul K . Leung

One measure of a health plan’s success can be found in how it identifies the minorities in the population it serves and whether it offers them culturally competent services.

The Minority Populations of Oregon

According to the Center for Population Research and Census at Portland State University, Oregon had (as of July 1, 1993) a total population of 3,038,000. Its minority population was made up mainly of four groups- Hispanics (4.6 percent), Asian Americans (2.7 percent), African Ameri- cans (1.6 percent), and Native Americans (1.4 percent). The African American and Asian American populations are located for the most part in the urban centers on the western side of Oregon. The Hispanic and Native American populations are more dispersed and are located in both urban and rural areas of the state.

Oregon has experienced a steady stream of Hispanic immigrants, par- ticularly from South and Central America. Many are refugees from the civil wars of several years ago in that area. These people differ culturally from the Hispanics who have come from Mexico. Members of these groups have been drawn to Oregon by the availability of employment in the agricultural sec- tor, but have also moved into lower-paying service sector jobs, such as fast food, janitorial services, and so forth. As a result, many do not have employment-based health benefits.

Chinese nationals came to Oregon over a hundred years ago. Since then, the Asian population in Oregon has grown steadily. A recent surge in these minorities was caused by an influx of people from Vietnam, Cambodia, and other Southeast Asian countries. Most of the Asian pop-

N b w D I R E C ~ , O N \ t - O R MENTAL HEALTH SERVICE>, no. 85. Spring 2000 D Jossey-Bass Publishers 105

106 WHAT THE OREGON HEALTH PLAN CAN TEACH Us

ulation resides within the tricounty area that makes up metropolitan Portland.

The African American population in Oregon is a very stable one in that many families of this community have been residents of the state for decades. Portland is home for the majority of African Americans in Oregon. Many originally came to Oregon as employees of the national railroads when Portland was a major railroad terminus for the Northwest.

Native Americans have obviously been in Oregon long before European American settlers arrived. There are Indian reservations in rural regions of the state and many Native Americans in the Portland metropolitan area. Mental health services are generally provided autonomously on the reser- vations, and linkages to the public mental health system are limited.

A minority group that has come to Oregon recently is from Russia. Esti- mates are that this group numbers about thirty thousand in the metropoli- tan Portland and Woodburn areas. The Russian immigrants have most recently been joined by refugees from Bosnia. Oregon is one of ten states that have taken in the majority of the Bosnian refugees.

Providing mental health services to the broad variety of minority pop- ulations in Oregon offers many challenges. Each subgroup presents the ther- apist with unique cultural characteristics that if not recognized can lead to communication problems and sometimes serious consequences. For exam- ple, in our western culture, it is commonly understood that the treatment of mental conditions will include a great deal of “talk therapy.” Medications may play a role but not necessarily a key role. Western patients also do not necessarily expect their primary medical practitioner to be the main men- tal health care provider or even involved in a significant way. However, in Asia the medical model is the predominant accepted approach. All care, both physical and mental, is provided by a physician and usually involves the dispensing of a medication, an injection, or similar physical treatment. When individuals from Asia come to the United States, they retain this per- ception. So if individuals from an Asian culture are suffering from a mood disorder, they would not understand or readily accept seeking help from a nonphysician provider. These individuals will respond best if their initial treatment is consistent with this traditional medical model.

The Indochinese program at Oregon Health Sciences University (OHSU) recognizes this critical cultural difference and adheres to such a traditional model from the very beginning of a patient’s treatment (Boehnlein and oth- ers, 1995). After trust has been established, the other elements of treatment, such as talk therapy, work therapy, occupational therapy, and so forth, are introduced. This approach has proven to be very effective for the OHSU Indochinese program over the past twenty years. Patients (and their fami- lies) who have gone through this process and have been treated by western methods report that it has been far more effective than their traditional treat- ment. Compliance rates are quite high. The OHSU mental health clinics are now incorporating this concept into the care of other minority groups.

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Because the number of possible points of view is enormous with such a broad array of minority groups, this chapter focuses on one particular group, the Indochinese minority. Many of these newcomers to the Oregon minority community are from the war-torn countries in Asia-Vietnam, Cambodia, Laos, Thailand-and have all suffered great losses of both loved ones and property. They are in need of extensive help and emotional sup- port. The author has worked extensively with this (and other) groups. This chapter asks, how prepared is the OHP to deal with patients who come from these distressed minority groups?

One of the first conceptual differences to be recognized and dealt with is that in the United States, in order to survive, one must have health insur- ance. That concept is totally foreign to most of the rest of the world. Tradi- tionally in Asia, when an individual went to see a healer, the doctor expected to be paid by the patient. Those individuals who had no money simply did not seek care. In the recent past, many of these countries have moved from this traditional fee-for-service system to a socialized system in which the government provided all services to its populace free of charge. Consequently, many newcomers to the United States from these countries are accustomed to going to a physician and paying nothing. Their obliga- tion has been to pay taxes to the state, and the state in turn has paid their health care providers. As a result, the complex U S . “system,” with its many insurance plans, claims requirements, eligibility requirements, and other quirks, is extremely confusing and intimidating to minority immigrants.

The OHP has actually helped many people in the Indochinese minor- ity groups who often qualify for the plan. Many recent arrivals from Asia are both physically and mentally disabled, so they are unable to find employ- ment and cannot purchase health insurance. Because an even larger num- ber of newcomers have language barriers, those able to seek employment must frequently do so in those sectors of the economy that pay minimum wages and do not offer their employees health benefits. The OHP has pro- vided these individuals adequate health insurance during their transitional period so they can better deal with language problems and gain necessary skills to improve their economic status.

How is the OHP meeting (or not meeting) the needs of the new minor- ity arrivals? They have many of the same problems that the poor European American population faces in that they also do not know where to go for help, nor do they know how to access the system successfully. The OHP has generally promoted the concept of the “gatekeeper” for physical health ser- vices. One must first go to a primary care physician, and that provider then refers the patient with special needs to the appropriate specialist. This con- cept is good in that there is one place to go for initial care. Unfortunately, ethnic minority people without the ability to speak English often have seri- ous problems maneuvering through the system. All too often, the offices, clinics, hospitals, and laboratories to which they are directed have no one on staff who can communicate with them in their native language. Large

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institutions such as OHSU claim to have interpreters available, but this “cadre” often turns out to be a single individual. This person cannot serve literally hundreds of patients equally well, equally promptly, or equally responsively.

Many minority patients will call an office seeking help only to be told that an interpreter will call them back, but sometimes no one ever calls back. Even in those instances when they have succeeded in making an appointment, they sometimes arrive only to find that the interpreter is not available due to some emergency or missed communication. They often have to wait for hours only to be told eventually that they will have to come back at a later date and time when there will be an interpreter present.

The Indochinese psychiatric program at OHSU has a long history and has over time developed good rapport with the primary care departments. So when the physicians in these departments see an Indochinese ethnic patient who they believe may have an emotional problem as well as a phys- ical problem, they will refer the patient promptly to this specialty clinic. The Indochinese psychiatric clinic has intake workers who speak the patient’s language and understand the patient’s culture and will quickly work the patient into their program. This program has also added staff conversant in Russian. As a result, the Asian and Russian refugees in the Portland area have good access to mental health services whose providers can communi- cate with them and be sensitive to their cultural differences. However, minority patients living outside the Portland metropolitan area have signif- icant problems accessing the OHP services to which they are entitled, because other areas of Oregon lack trained multilingual professionals.

Case Study A single Vietnamese mother with three children (one of whom is a preteen) is employed and speaks just enough English to survive day to day and at her job. She has OHP coverage and so has access to medical care. In the course of seeing her primary care physician for routine health care, she vents frus- tration over the difficulty she is having dealing with her Americanized pre- teen son. The doctor offers to refer her to a counselor, who might be able to help her with this problem. She readily agrees to this referral because she wants to be involved in her new cultural processes.

The mental health counselor begins the session by asking the Viet- namese woman what her problem is. She responds by telling the counselor about her life and the stresses she is experiencing trying to raise three chil- dren alone. In the course of the conversation, she says, “Sometimes I feel like I just want to die because it is all too much.” The counselor immedi- ately picks up on the statement about her wanting to die. “Are you suici- dal?” she asks. “Sometimes I do think about that,” the woman responds. The counselor then asks what she would do with her children. She says that she would take them along. Because the counselor is not knowledgeable in

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the woman’s native culture, she does not know that this comment is a very common one among Asian women under stress but that they very rarely (if ever) act on it. It is a comment made in her culture much as an American mother says to a misbehaving child, “I’m so mad at you, I could scream!”

The counselor immediately implemented all the procedures required by the clinic’s protocol when dealing with a suicidal patient. She demanded to know where the patient’s children were and asked the woman to sign an agreement that said she would not harm her children and that she would come back the next day to see the counselor again. The patient refused to sign because she had no idea what the counselor was talking about, nor would she come back the next day (a Saturday), as she had plans to spend the day with her family. She left the counselor’s office with the issues unre- solved. The counselor then spoke to her supervisor, and they believed that the only option to ensure the woman’s safety was to report this concern of a potential suicide to 9 1 1.

While returning home, the patient was stopped by the police, who handcuffed her and took her to the crisis triage center because everyone now believed this was a dangerous person not only to herself but also to her children. The appropriate child welfare agency was notified, and they took the three children into custody. They were quickly placed outside the home. Fortunately, there was a grandmother (the patient’s mother), so the children were placed in her home. The mother was then told that unless she promised not to kill herself or her children, she would not be allowed to see them.

Fortunately, someone at the child welfare agency suspected that the woman was not suicidal and contacted the OHSU Indochinese psychiatric program and arranged for a senior Chinese psychiatrist to intervene. When he heard the woman’s story, he also realized what had happened, so he wrote a report for the judge who would be hearing her case and asked for some consideration. The psychiatrist was able to explain to the patient that in the western culture, she should not make comments such as she had made to the mental health counselor. Eventually, the woman was given back her chil- dren. Had she seen a counselor with some appreciation of her ethnic cul- ture, her comment about sometimes wanting to kill herself would have been taken in a more ethnically appropriate way, and the results would likely not have been as severe.

Discussion

This example makes it clear that just having a plan for insurance coverage is not enough. In order for it to work to the benefit of the population being served, the service providers in the plan need to have special skills in deal- ing with the various ethnic groups. They need both language skills to com- municate with the patients and some understanding of the minorities’ cultural mores in order to minister effectively to the people’s health needs.

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Furthermore, a person’s treatment should include social supports-hous- ing, employment, social network, and so forth. If the patient is a European American suffering from schizophrenia, for example, the attending thera- pist knows of community resources where that patient can receive the appropriate social support. Some social resources have been created for the Indochinese community in Oregon. However, if the patient is a recent Russ- ian immigrant, a therapist can prescribe medication, but there is no Russ- ian foster home to which the person can be sent. As a result, the patient will go home to his or her family, who may be unable to provide adequate sup- port.

Fragmentation of the service system is another problem. For example, prior to the implementation of the OHP, the few minority mental health providers were often called on to serve as primary care physicians, especially in the Indochinese community. Patients came to their Indochinese clinic psychiatrists for treatment of their physical as well as mental illnesses. The OHP has changed that system. The clinic psychiatrists must now refer these patients to the appropriate primary care physician for treatment. This requirement has necessitated the reeducation of the Indochinese psychiatric clinic’s clientele at OHSU. Many recent immigrants and refugees do not have the skills or knowledge to work within the complicated system that has been created by the OH€? Paradoxically, immigrants with mental health problems no longer have a single point of entry.

Because language is not a barrier to treatment for African Americans, they can seek care at any of the mainstream mental health facilities in Ore- gon. Prior to the OHP, there were several community mental health clinics serving African Americans in the greater Portland area. Because the mental health phase-in of the OHP did not occur in Portland, no immediate changes were encountered. However, as the mental health aspects of the OHP have been implemented statewide, some of these centers have seen significant change. Several programs were incorporated into larger organi- zations, prompted in part by issues predating the OHP and in part by con- solidation forced by managed care models that favor large networks of providers.

Although there are several primary care clinics in Oregon that serve Hispanics, the lack of trained Latino mental health professionals to work with this population remains an issue. There is a significant need for indi- viduals to oversee or coordinate mental health treatment programs and for a centralized, identifiable mental health facility focusing on the Hispanic population.

The Native American population is another minority group that has seen little change in mental health services under the mental health phase- in. They are allowed to exempt themselves from enrollment in managed care. Much of the care is provided to Native Americans living on or off reser- vations by tribal or Indian Health Service centers that may receive OMAP funds as federally qualified health centers. Recently, several Oregon tribes

MULTIC~JLTURAL MENTAL HEALTH SERVICES 11 1

have used earnings from casinos to fund health clinics for their members, and these clinics do have counseling services available. Native Americans willing to go to community mental health clinics are able to seek care at the mainstream treatment facilities if they are qualified for the OHE In practice, however, this group is a low-visibility minority population for the average OHP provider.

Looking forward, the following issues deserve particular attention:

Total integration of mental health care (together with physical health and chemical dependency treatment) into one single program that has exper- tise with a particular minority group Improved availability of interpretive services for programs that seldom see members of different-language minorities Dissemination of information within the minority community about pro- grams that are available Culturally informed liaison between primary care physicians and mental health providers

In summary, the various minorities living in Oregon suffer from many of the same mental illnesses as the European American majority (Kinzie and others, 1990; Leung, Faulkner, McFarland, and Riley, 1993), yet they are relatively few in number, and their needs have not received sufficient atten- tion. The OHP has been invaluable in offering mental health benefits to many, but the programs that exist are frequently not well-known to that sec- tor of the community. The situation is especially problematic if the person does not speak or understand English. Many of the more recent arrivals come from a culture that has not treated mental illness in the same way it is treated here, so these individuals are leery of the medication-plus-talk- therapy approach. In order to treat them successfully, the therapist must first obtain their trust. This approach takes time, and in today’s health care deliv- ery climate, time is very valuable. The early phase-in of the OHP mental health program appears promising, but its benefits for minorities are yet largely unrealized.

References Boehnlein, J. K., and others. “A Comparative Study of Family Functioning Among Viet-

namese and Cambodian Refugees.”Journal of Nervous and Mental Diseases, 1995,183,

Kinzie, J. D., and others. “The Prevalence of Posttraumatic Stress Disorder and Its Clin- ical Significance Among Southeast Asian Refugees.” American Journal of Psychiatry,

Leung, P. K., Faulkner, L. R., McFarland, B. H., and Riley, C. “Indochinese Patients in the Civil Commitment Process.” Bulletin of the American Academy of Psychiatry and

768-773.

1990,147,913-917.

Law, 1993,21, 81-89.

112 WHAT THE OREGON HEALTH PLAN CAN TEACH US

PAUL K. LEUNG, M.D., is associate professor and director of clinical services in the Department of Psychiatry and director of the Indochinese Psychiatric Pro- gram at Oregon Health Sciences University.