CULTURAL COMPETENCY & MENTAL HEALTH. Joan (Nyala) Cooper, Ph.D. Charles R. Drew University of Medicine & Science Adjunct Assistant Professor, Department of Psychiatry & Human Behavior Consultant, National Minority AIDS Education & Training Center
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Joan (Nyala) Cooper, Ph.D.
Charles R. Drew University of Medicine & Science
Adjunct Assistant Professor, Department of Psychiatry & Human Behavior
Consultant, National Minority AIDS Education & Training Center
Pacific AIDS Education & Training Center
This session is intended to assist participants with cultural competency skill building in the area of HIV Mental Health. Participants will have the opportunity to:
The Bio-psychosocial model incorporates the three major spheres of
social into …
the context of culture.
The Cultural Context
Marilyn Martin, psychiatrist, psychoanalyst and author of Saving Our Last Nerve: The Black Women's Path to Mental Health, speaks on depression and how mental health is innately connected to physical health. (Central Texas African American Family Support Conference – Austin Travis Mental Health Mental Retardation Center, 2003)
John Anderson, Ph.D. (2005) states that a solid working knowledge of mental health and substance abuse issues is essential for understanding how to help people protect themselves from HIV infection, how to help those who are already infected from transmitting the virus to others, and how to reduce adverse health consequences among those living with HIV.
He underscores the link between HIV and mental health by citing the results of the Eric Bing, M.D., et. Al.(2001) HCSUS study that examined mental health and substance abuse in a large, nationally-represented probability sample of adults receiving care for HIV in the U.S. Nearly half of the sample screened positive for a mental health disorder. The results also indicate the high proportion of people receiving HIV-related care who also have mental health and substance abuse problems. In addition to their negative impact on quality of life (Sherbourne et al; 2000), mental health and substance use disorders have been consistently associated with increased HIV risk behavior (Hutton et al; 2004; Booth et al; 1999) as well as poor access and adherence to anti-retroviral treatment for HIV/AIDS (Cook et al; 2002; Tucker et al; 2003).
While Anderson states that mental health and substance use disorders are highly treatable, they must first be identified and referred to appropriate services. He finds it unfortunate that “stigma and lack of knowledge about these disorders often prevent this from happening (Cooper et al; 2003; Kessler et al; 2001).”
The problem of client under-recognition of mental health problems is compounded when HIV providers lack the experience to adequately assess mental health needs. He states “Primary care providers are not well-equipped to diagnose and treat common mental health disorders (Staab et al; 2001). Additionally, prevention workers and prevention case managers typically receive few guidelines and minimal training in the systematic assessment of mental health and substance use disorders.”
The role of the front line mental health professional treating persons with mental illness and HIV/AIDS has become more complex as the disease and the treatment for it changes.
Persons with mental illness are often at greater risk for HIV infection and progression than the general population because of the characteristics of their illness. Those with severe, chronic (CMI), or serious and persistent mental Illness (SPMI) have increased risk due to:
(HOPE Curriculum, APA, 2000)
People with HIV and people at highest risk for HIV are diverse, in terms of everything from race and ethnicity, gender, and sexual orientation, to age and socioeconomic status.
Since HIV counselors must explore particularly sensitive issues – including sexual activity, substance use, and disease – it is crucial that counseling be well-grounded in concepts of cultural competence.
The issue reviews definitions of cultural competency and the ways in which cultural competence is consistent with and builds upon client-centered counseling skills and a counselor’s willingness to learn from clients.
HIV Counselor Perspectives (April, 2004) states that there are two main schools of thought about cultural competence. They relate that the first suggests that counselors should learn beliefs and norms of the specific cultures they are working with and mirror those cultures (Wilson,& Miller, 2003; Snowden & Jerrell, 2003). The second suggests that culturally competent counselors focus on learning skills such as openness and active listening that allow them to uncover an individual client’s culture and level of acculturation in the course of the counseling sessions (Fullilove, M, 1998; Houston-Hamilton, A., 1998; Jue, S. 1988; and HRSA, 2001).
The authors further indicate that recently, researchers have re-examined how counselors and practitioners view “culture” and the cultural models on which prevention strategies are built. In their examination, Airhihenbuwa et al; 2000 and Yoshikawa et al; 2003 look at the models and definitions to see how they may perpetuate the perception that clients who are different are “outsiders” and how this perception may impede efforts to reach those in need of service.
Culture is a set of shared behaviors, ideas and values which are symbolic, systematic, cumulative and transmitted from generation to generation. (L.A. County, Dept. of Health Services)
“Culture is a particular set of values, norms, attitudes, and expectations about the world that shapes the personalities of those reared in that culture.” (Marin, 1991)
Cultural Competency has been defined as a “set of academic and interpersonal skills that allow individuals to increase their understanding and appreciation of cultural differences and similarities within, among, and between groups.”
(L.A. County, Dept. of Health Services)
The authors of “Cultural Competence and HIV” state that Marin’s definition of culture avoids the problem that others have identified: in the HIV prevention field, as in other areas, “culture” may refer only to racial and ethnic minority status, even though White and heterosexual people, for example, were also raised with values, norms, attitudes, and expectations (Wilson, 2003).
They further state that others warn that when only non-European peoples are seen as having “culture,” their non-European ways are defined as barriers to their progress, subtly linking the ideas of “culture” and “barrier” (Houston-Hamilton, 1998; Airhihenbuwa et al, 2003).
They identify a third category of “others” who suggest that culture is influenced not only by race or ethnic background but also by other demographic factors such as age, socioeconomic or immigration status, sexual orientation, and history of oppression (Brooks et al, 2003; Diaz, et al, 2000).
6. Physical Abilities and Qualities
7. Sexual /Affectional Orientation
8. Childhood Experiences and
Family Factors (Family religion, place of birth and household location, family social class, parents occupations, etc.)
2. Geographic Location
4. Marital Status
5. Military Experience
6. Parental Status
8. Work Experience
9. Current Social Class
1. Experiences with Immigration, Exile, etc.
3. Degree of Assimilation
1. Cultural sensitivity or awareness (being conscious of the nuances of other cultures and one’s own culture)…leads to
2. Cultural knowledge (understanding cultural differences, seeking accurate information about a cultural group),…which results in
3. Cultural competency (the fusing of sensitivity and knowledge with behaviors that enhance interaction among persons from varied cultures)
(Kavanagh & Kennedy, 1992; Torres,1993)
Cultural infusionreflects the extent to which ethnic/cultural characteristics, experiences, norms, values, behavioral patterns and beliefs of a target population, as well as relevant historical, environmental, and social forces, are incorporated in the design, delivery, and evaluation of targeted health promotion materialsand programs.(Myers, Linda James, 2003)
(Surface Structure usually increases the receptivity, comprehension, or acceptance of messages.)
(Deep Structure conveys salience and determines program or message impact.)
(Myers, Linda James, 2003)
“Historical racism, sexism, and homophobia, both in society and in the medical establishment, build barriers for many people seeking to access health care, including HIV testing. In particular, there is a legacy of mistrust around the treatment of sexual issues by the American medical establishment.”
- The Tuskegee Study
- Sterilization without Knowledge or consent
Racism, sexism, and homophobia can have powerful effects on:
- communication style
- body image
- feelings of control
which in turn, can diminish a client’s sense of
- ability to negotiate
- and capacity to employ harm reduction strategies.
Erving Goffman, whose seminal work "provides the theoretical underpinnings for much of the literature on stigma and stereotyping" (Health Resources and Services Administration, HIV/AIDS Bureau [HRSA/HAB], 2003), defines stigma as "an attribute that is deeply discrediting" and reduces the stigmatized individual "from a whole and usual person to a tainted, discounted one" (Goffman, 1963, p. 3).
HIV infection fits the profile of a condition that carries a high level of stigmatization ... .
The result is the widely documented phenomenon of HIV-related stigma. "HIV-related stigma refers to all unfavorable attitudes, beliefs, and policies directed toward people perceived to have HIV/AIDS as well as toward their significant others and loved ones, close associates, social groups, and communities. Patterns of prejudice, which include devaluing, discounting, discrediting, and discriminating against these groups of people, play into and strengthen existing social inequalities – especially those of gender, sexuality, and race – that are at the root of HIV-related stigma" (HRSA/HAB, 2003).
Rate Yourself on a scale of 1 to 5 (1 = low and 5 = high)
DOING: How good are you at:
BEING: How good are you at:
Total score: ____
Scores 70 to 61 = highly competent
Scores 60 to 51 = moderately competent
Scores 50 & below = need more practice
Revised by Dr. Mikel Hogan Garcia. California State University at Fullerton. in 1990 from materials developed by C. Dodd and F. MontaJzo. Intercultural Skills For Multicultural Societies (1987) and G. Ferraro. The Cultural Dimension of International Business (1990).
[This case study is taken from “Cultural Competence and HIV,” HIV Counselor Perspectives, Vol. 13, 2, April 2004.]
At the end of a busy antibody test counseling shift, Gloria, a 37-year-old African American test counselor looks up to see Susan, a 24-year-old White woman and a new counselor, leaning against the doorframe and looking uncomfortable. Gloria, an experienced counselor, invites Susan in and asks her how her last session went.
"She was negative, thank God," Susan says. "But, there were a couple things I wanted to check out with you. I feel kind of stupid, since we just had that class on cultural competence. Do you have time to give me some feedback?"
As Susan tells her story, it becomes clear that there were a few snags in Susan's session with Louise, a 65-year old African American woman and first-time tester. "Somehow we got sidetracked onto how the AIDS epidemic got started. At first, I felt really good talking about that, because I know a lot about it and I thought I could build trust by showing I was knowledgeable. But then it started cutting into our risk assessment time and I began to rush through
the assessment questions. The client looked offended and got really quiet, and I was really conscious of being this White woman asking her these really personal questions.
"Finally I just said ,'I'm new at this and I don't feel like I'm doing a good job connecting with you. Can we go back a few steps? Is there a way I can be more helpful?”
Gloria praises Susan's decision to seek consultation. She says that she is familiar with African American clients asking about how AIDS began. 'It sounds like you might have felt a little insecure, and here was a chance to show your credibility, but then you got sidetracked. How do you think it would have been for you to say, 'A lot of people have asked me that, and there are lots of theories. What have you heard? What makes sense to you?'" Susan agrees that this approach could have given her a better window into Louise's world View.
Gloria continues, "And you're right to think she might be checking out your credibility. This woman lived through Tuskegee. Still, remember to move on: everybody has a story, and listening to that story can take us to the next step, but stay focused on the client's risk-related needs."
"Another thing that I noticed was that you said you got rushed doing the risk assessment questions," Gloria observes. "Remember, you aren't just a White woman and a stranger: you're young enough to be her daughter. And she has never tested before. She's new to our 'culture.' Maybe going through the risk assessment abruptly felt intrusive. Sometimes, I introduce the assessment by saying, 'I'd like your permission to ask you some personal questions about things like sex and drugs. Your answers are confidential, and I hope we can use them to identify some steps that will help you protect your health. “Probably the most important thing you can do with any client is to show respect and a willingness to listen."
Gloria adds, ''It sounds like you already know that, because your gut told you things weren't working out and that you needed to reconnect with Louise. What happened when you acknowledged the problem and asked Louise what you could do to connect better?" Susan says that Louise became a little tearful as she recounted how a friend from church had lost a son to
AIDS. As Susan eased back into the risk assessment, Louise shared more openly. "She even ended up taking some textured condoms to use with her 'special friend. 'I was a little surprised those would catch her eye." Gloria says, "So you were able to recover, and Louise helped you see where she needed to go next Remember, our clients don't expect us to know everything about AIDS or about them. Be interested and learn all you can in the time that you have." Gloria grins, 'We'll talk about your assumptions about senior citizens and sex next time."
Dr. John McNeil (2004) A panel of multidisciplinary and multi-Diaspora healthcare providers developed a model for dealing with minority patients infected with HIV. Process steps include: Workshop; Literature search; Model development; Focus group feedback.
BARRIERS TO CARE -
SENSITIVITY OF PROVIDER -
Improving communication skills is moving toward cultural competence.
When an appropriate native speaker is not available, an English speaking therapist may have to see the client.
Patients whose English is limited report that they take many cues from the listener's face. They report that a good listener:
speakers may find hard to understand.
*Derived from the County of Los Angeles Commission on Human Relations booklet "How to Communicate Better with Clients. Customers and Workers Whose English is Limited," (Developed by Carole Chan).
SUMMARY & CLOSING COMMENTS