Cultural Competence & Mental Health in Primary Health Care

Presented by: Ruth Tadesse, MS, RN

Date: 12/04/2014

Disclosures and Learning Objectives

• Learning objectives:

• Explain the use of 2 cultural assessment tools

• Discuss culturally competent interventions that can be used when providing mental health care in primary care setting

• Identify 5 cultural competence clinical guidelines

Disclosures: Ruth Tadesse has nothing to disclose.

What does culture got to do with it?

• Review DSM V cultural formulation

• Review IOM reports on mental health and addictive disorders

• Discuss different cultural assessment tools and interventions

• Next week topic

What is the right term to use?

• Cultural knowledge

• Cultural sensitivity • Cultural awareness

• Cultural tolerance

• Cultural acceptance • Cultural encounter

• Cultural competence

Cultural Competence Defined

“To be culturally competent doesn’t mean you are an authority in the values and beliefs of every culture. What it means is that you hold a deep respect for cultural differences and are eager to learn, and willing to accept, that there are many ways of viewing the world.”

Okokon O. Udo, PhDhttp://xculture.org/cultural-competency-programs/about-cultural-competency/

“Every encounter is a cross-cultural encounter.” Robert C. Like, MD, MS

http://rwjms.umd`nj.edu/departments_institutes/family_medicine/chfcd/index.html

• Are we similar or are we different?

Or could we just be walking in different shoes and gaining different life experiences?

Assessment tool: Cultural Formulation Interview (CFI)

• CFI -16 questions to ask the individual patient• Informant Version – 17 questions to ask

families/caregivers• Supplementary Modules – comprehensive questions

including, age specific questions, spirituality & religion, immigrants & refuges http://www.psychiatry.org/practice/dsm/dsm5/online-assessment-measures#Cultural

CFI located in DSM-5

IOM Report on Mental Health & Addictive Disorders: The Six Aims of High-Quality Health Care

• Safe - Avoiding injuries

• Effective – Avoiding underuse and overuse

• Patient-centered – Individual patient preferences

• Timely— reducing waits and sometimes harmful delays

• Efficient—avoiding waste

• Equitable— providing care that does not vary in quality http://www.ncbi.nlm.nih.gov/books/NBK19817/

Why should we care about culture?

• Racial and ethnic minorities comprise 26% of the total population of the United States.

• In Oregon:

http://quickfacts.census.gov/qfd/states/41000.html

2010 2000 1990

White 78 % 83% 91%

Latino 12% 8% 4%

African American 2% 2% 2%

Asian 4 % 3% 2%

Native American 2.1% 2% 1%

Multiracial 2.8% 2.4% ND

Other 0.1% 0.1% 0.1%

Cultural Differences in Mental Health

• Racial minorities are more likely to report depressive symptoms to PCPs than to mental health specialists (Snowden, 2001).

• Racial, ethnic and cultural minority fear the negative consequences of mental health care (Inerian, et al , 2013).

• Mental health plays a major role in physical health and vice versa (Kessler et al, 2005; Mauer, 2003; Lando et al, 2006).

Cultural Differences in Mental Health

• As many as 70% of issues in primary care setting stem from psychosocial issues (Robinson & Reiter, 2007).

• To provide optimal care for a psychiatric patient, modes of treatment has to be individualized (Holden et al, 2014).

• Minority patients are among those at greatest risk of non-detection of mental disorders in primary care (Holden et al, 2014).

Ideals of Mental Health Dimensions of Cultural Difference

EASTERN’

• Harmony with other people (other valued)

• Relationships• Balance (‘ecological’)

• Keep outer world constant (conform with society)

• Freedom of inner experience (variety of inner experience)

www.sumanfernando.com

‘WESTERN’

• self sufficiency & self-esteem valued

• Personal autonomy• Efficiency (‘machine like’)

• Keep inner world constant (control altered states of consciousness)

• Freedom of expression (variety in behavior)

Cultural Competence Clinical Guidelines in Mental Health

• Explore the meaning of the aberrant behavior from the client’s point of view

• Avoid projection of the clinician’s worldview on the client

• Be aware of the cultural context of help-seeking behavior

• Recognize that mental health disorders are complex and are influenced by culture

• Be aware of self cultural competence to avoid influences of the therapeutic relationship

Group therapy in other cultures

Assess using BATHE Method – ~1 minuteLieberman, J. A. & Stuart, M. R. (1999)

Background

Affect

Troubles

Handling of the current situation

Empathic response

“What is going on with your life? Tell me what has been happening since I saw you last?”“How do you feel about what is going on?”

“What troubles you about this?”

“How are you handling that?”

“Sounds like things are difficult for you.” “Let’s schedule you to see one of our behavioral staff.”

Intervention: CRASH Course (Rust et al., 2006)

• Considering culture• Showing Respect• AAssessing/Affirming differences• Showing sensitivities/self-awareness• Do it all with Humility

Each person is the world expert of their own condition.

What is the danger of not considering culture of the patient?

To be continued…

Next Week'sTopic:

Psychopharmacology with Dr. Betlinski or Dr. Hamer

The human mind is like an umbrella.

It functions best when it is open.

–Max Gropius

References

Center for Healthy Families and Cultural Diversity Department of Family Medicine/UMDNJ -Robert Wood Johnson Medical School www2.umdnj.edu/fmedweb/chfcd/INDEX.HTM

Cross Cultural Health Care www.xculture.org

CultureMed www.sunyit.edu/library/html/culturemed/

Culturally and Linguistically Appropriate Services (CLAS) United States Department of Health and Human Services Office of Minority Health www.omhrc.gov/clas

Diversity in Medicine www.amsa.org/div

Ethnomed http://healthlinks.washington.edu/clinical/ethnomed

Holden, K., McGregor, B., Thandi, P., Fresh, E., Sheats, K., Belton, A., Mattox, G., & Satcher, D. (2014). Toward Culturally Centered Integrative Care for Addressing Mental Health Disparities Among Ethnic Minorities. Psychological Services. 11(4). pg. 357-368.

Ideals of Mental Health Dimensions of Cultural Difference www.sumanfernando.com

Initiative to Eliminate Racial & Ethnic Disparities in Health http://raceandhealth.hhs.gov

Institute of Medicine (2005). Improving the quality of health care for mental and substance-use conditions: Quality Chasm Series. Washington, DC: National Academies Press.

Institute of Medicine (2001). Unequal Treatment: What Healthcare Providers need to Know About Racial and Ethnic Health Disparities. Quality Chasm Series. Washington, DC: National Academies Press.

Initiative to Eliminate Racial & Ethnic Disparities in Health http://raceandhealth.hhs.gov

Lieberman, J.A., & Stuart, M. R. (1999). The Bathe Model: Incorporating Counseling and Psychotherapy Into the Everyday Management of Patients. Primary Care Companion Journal of Clinical Psychiatry 1(2): pg. 35-39.

Mental Health: Culture, Race, and Ethnicity: A Supplement to Mental Health: A Report of the Surgeon General. http://www.ncbi.nlm.nih.gov/books/NBK44246/

National Center For Cultural Competence (NCCC) www.georgetown.edu/research/gucdc/nccc/

“Race” and Culture Issues in Mental Health and Thought Identity http://webcache.googleusercontent.com/search?q=cache:NhVH6TEqdIAJ:www.oise.utoronto.ca/cdcp/UserFiles/File/Conferences%26Seminars/Conference%2

Resources for Cross-Cultural Health Care www.diversityrx.org

Rust, G., Kondwani, K., Martinez, R., Dansie, R., Wong, W., Fry-Johnson Y., & Strothers, H. (2006). A CRASH-Course in cultural competence. Ethnicity & Disease, 16(2, Suppl.3), S3-29-36.

Searight, H., R., (2009). Realistic Approaches to Counseling in the Office Setting. American Family Physician. 79(4): pg 277-289.

Transcultural and Multicultural Health Links http://web.nmsu.edu/~ebosman/trannurs/index.shtml

References