Slide 1

Cultural Competence
Integrating Differences
into Community Services

Objectives
Understand Stigma.
 Understand Culture Competency.
 Learn Culturally competent care for
people with Mental Health, Mental
Retardation and Addictions.


We live in an world
which often separates us.
Racism
 Sexism
 Ageism
 Feminism
 Classism
 Atheism


“Different” people are
“Stigmatized”

Mentally retarded inmates in a sanitorium in Germany

Stigma
Definitions from the U. of Chicago PSR Training Manual

“Stigmas are negative attitudes about a
group that lead to depriving them of
some fair opportunities.”

Stigma is related to…..
Stereotypes
Prejudice
Discrimination

Stereotypes
from The Asian Health Coalition of Illinois

Stereotypes are exaggerated beliefs
or fixed ideas about a person or
group which is held by people and
sustained by selective perception and
selective forgetting.

Prejudice
from The Asian Health Coalition of Illinois

Prejudice is a preconceived idea or
negative attitude formed before the
facts are known and sustained over
generalizations. A bias without
reason, resisting all evidence…

Discrimination
from The Asian Health Coalition of Illinois

Discrimination refers to treatment in
favor or against a person based on
the group to which that person
belongs and not on merit.

Stigmatized People…..
Experience being stereotyped and
are often the object of
discrimination and prejudice.

People are often stigmatized by:













Mental Illness
Mental Retardation
Physical Disability (including blindness, deafness)
Alcoholism /and or Drug Addiction
HIV or AIDS, Cancer or other terminal illnesses
Criminal behavior
Poverty
Alternative Lifestyles/sexual orientation
Wheelchair bound
Gender
Obesity

All our Consumers belong to
stigmatized groups!

Stigmatized People
Consumers and their families
can’t navigate the bureaucracy
even if resources are there.
It’s too frustrating!

Use People First Language
“I am more than my
illness….Don’t call me
“the schizophrenic,
“the addict” or
“the retard.”

As human beings, we have many
similarities…..
But, who we really are, is often
derived from our original family of origin
and our current lifestyle.

The Bottom Line:
People are different, even within
their own culture!
These differences matter when
planning and providing services.

National Mental Health
Association
“For Mental Health consumers, both
access to the services and the effectiveness
of the care they receive are greatly affected
by the degree to which the delivery system
is“culturally competent.”

Some important definitions
Related to Cultural Competency

Culture

from King,et. al

The Office of Special Programs, U.S. Dept. of Education

“The integrated patterns of human
behavior that includes thoughts,
communications, actions, customs,
beliefs,values, and institutions of
racial, ethnic, religious, or social
groups.”

Cultural Sensitivity
An awareness and respect of a
person’s cultural beliefs and
values.
Culhane-Pera, et .al

Cultural Competency
 Skills

(that translate into)
 Behaviors, Practices, Attitudes, and
 Policies
That enable an individual, agency, or
system to effectively serve culturally
diverse communities.
from The Asian Health Coalition of Illinois

Here at Hill Country MHDDC
Consumers are very diverse in their
language and culture.

61% of our Consumers are
Caucasian Americans
Many have German
backgrounds.

Our Consumers are …..

n
1% NativeAmerican

33% Hispanic
1% Asian

3% African
American

1% are “Others”

Consumers Have Many
Different Lifestyles

Lifestyles

They have many different
beliefs.

Can We Communicate?
Think Language first!
 Do we need an interpreter?
 Communicate respectfully.
 Be sensitive to the consumer and the family.
 Consider your dress, tone of voice, eye contact,
location, seating arrangement, privacy, etc.


Is our approach culturally
appropriate?
“What do you call your problem?”
“What name does it have?”
“What do you think caused your problem?”
“Why do you think it started when it did?”
From Arthur Kleinman’s question protocol in“Culture,Illness, and Care:
Clinical Lessons from Anthropologic and Cross Cultural Research”,
Ann.Intern.Med. 1978:Vol.88, pg.251-258

Important Issues to Consider…





Impact of religion.
How are women, men, elders, and children
treated in their culture?
Is there domestic violence?
Ethnic minorities generally underutilize
outpatient services, although African-Americans
are over-represented in inpatient setting.

Diagnosis






Minorities with Bipolar Disorder are often
diagnosed with schizophrenia. (Mukherjee,et al)
African Americans are over diagnosed with
schizophrenia and under diagnosed with mood
disorders. (Bell )
A mental health consumer’s addictions may not
be treated.
The elderly may not be assessed for substance
abuse or alcoholism.

Diagnosis
A person with a primary addiction problem
might not be treated for a co-occurring mental
illness.
 Learning disabilities may not be identified in
individuals with mental illness or substance
abuse.
 A person with mental retardation may not be
treated for mental illness or substance abuse.


Diagnosis
Post Traumatic Stress Disorder is often
undiagnosed in people suffering from
Domestic Abuse or other trauma.
 Children who are witnessing or are
victims of domestic abuse or another
trauma, may be misdiagnosed with
Attention Deficit Hyperactivity Disorder.


Medication Differences





Asians and Hispanics need lower doses of antipsychotics.
African Americans use the same doses of antipsychotics, but lower doses of lithium.
The elderly need lower dosages of medications.
Thus, metabolism of drugs varies with age and
ethnicity and is critical in prescribing
medications.

From “Making Room for Culture in Psychiatry” by Lin, et al.

Pain Tolerance
Men and women tolerate pain differently.
 Cultures tolerate pain differently.
 People with addictions develop a
hypersensitivity to pain.
 In certain cultures, self-inflicted pain is a
part of a religious experience.


Religion





Religious beliefs shape how the world is viewed.
Is illness a punishment? The devil’s work? An
evil spell? Bad karma?
For Hispanics, the curandero is a trusted healer.
For Lakota Sioux, the ritual Vision Quest,
praying and fasting at a holy site is life
changing.

Remember there are as many
differences
Between individuals in the same
culture as there are between
individuals in different cultures!

Two African American
families, one lesbian
and the other, multi-racial.

German Consumers
Suggestions from our Gillespie County MH staff

What generation German?
 Would they feel more comfortable
speaking in German?


A consumer reacting to internal stimuli.

German Consumers
Suggestions from our Gillespie MHC staff in Fredericksburg

They may be resistant to seeking
mental services.
They may be reluctant to take medication.
They may “keep things within the family.”
They are concerned about the stigma.

German Consumers
They may feel it’s a character flaw or a
disgrace.
 They are very concerned about
confidentiality.
 Drinking alcohol is an accepted part of
their culture.
 Teen drinking may be acceptable in their
family.


Hispanic Consumers
from the U.S. Census, 1/23/03 Houston Chronicle

Hispanics are the largest minority group in
the U.S. with 37 million people.
 Texas is approximately 32 percent
Hispanic
 11.5 % African American,
 3.3% Other
 53.1% Anglo


Treatment Issues for Hispanic
Consumers
Do we need an interpreter?
 Is the person Tejano or from Mexico?
What generation Hispanic?
Is the person using a curandero?

Treatment issues for Hispanic
Consumers
Hallucinations are natural in their
religion.
 Hearing the voice of a loved one or having
hallucinations might be an expectations
when celebrating the Day of the Dead.
 Hispanic families are patriarchal.


Hispanic Consumers and
The Day of the Dead
A man is dressed in a skeleton
costume to portray death
in a celebration of
Dia de los Muertos,
The Day of the Dead.
People visit the graves of their
dead relatives to honor them.

Native Americans

Treatment Issues for Native
American Consumers
 Impact of racism,unemployment,and poverty.
 Coping with reservation life and
assimilation in mainstream culture.
 Consider the obesity, diabetes,
hypertension, and alcoholism in adults
and fetal alcohol syndrome in children.
 High use of native healers in the Southwest.

African Americans

African Americans
from the Houston Chronicle, 1/23/03

There are 36.2 million Americans who
identify themselves as “black only.”
 37.7 million identify themselves as “black
and at least one other race.”
 11.5% of Texans are African Americans.


Treatment Issues for African
American
Assess for co-occurring substance use
disorders and alcoholism.
 Address complications of obesity,
hypertension, diabetes,congestive heart
failure, asthma, and cancer.
 Sickle cell anemia is another illness
specific to African Americans.


Treatment Issues for African
Americans
Matriarchy; Mom or grandmother are the
dominant family figures.
 Lack of male role models and intact
families.
 Extended family or the Church may be
supports.


Treatment Issues for African
Americans


There is discrimination within their own
group based on skin color, hair texture,
class, values, etc.

Treatment Issues for Asians

Asians rarely seek help until its very severe.
Asians have extremely low admissions to state hospitals.
Mental illness is considered shameful. It’s hidden.
Is an interpreter needed?

Treatment Issues for Asians
Focus on physical symptoms.
 Asians are sensitive to medication.
 Give ½ the standard dose.
 Asians may use traditional healers and
herbal medicine.
 Asians may “flush” when drinking
alcohol.


Asian Consumers

Acupuncture has been used to treat
pain, schizophrenia, depression, and addictions.

Treatment Issues for Asians
Asian Cultures are patriarchal.
 The males in the family have the authority.
 Asians are more formal and inhibited in
their social behavior.


Older Adults

Treatment Issues for Older
Adults
Are they aware they need help?

Treatment Issues for Older
Adults
Is their mental illness caused by medicine?
 Do their medical problems cause or
complicate their mental illness?
 Is there Elder Abuse?


Gay Men and Lesbian Women
May struggle with homophobia and“being in the
closet” at work and with their families.
Gay people may want marriage, children, partner
benefits, etc., but may endure legal barriers.

Gay and Lesbian Women
Gay people often have specific health
issues related to their sexual practices.
 HIV, AIDS and STD’s are still concerns
with Gay men.
 People may be grieving the death of a
partner or friends who’ve died from AIDS,
or coping with living with AIDS or being
HIV+ themselves.


Treatment Issues for Gay and
Lesbians
Explore childhood abuse issues and
Domestic Violence..
 Assess for substance use and alcoholism.
 Sex enhancing drug use may be common
among some gay men.


Physically Challenged
Can they get to treatment?
Deal with their frustration and depression
Re: their disability.
 Do they need vocational assistance?

Mentally Challenged

Treatment Issues of Mentally
Challenged
They need to have meaningful activity
and purpose in their lives.
 They need to feel acknowledged and
appreciated.
 They need safety, structure, and security.
 Lack of continuity can cause crisis!
 They may need vocational assistance.


Winona Ryder

December 12, 2001,
Winona Ryder shoplifted
$5,560.40 designer items
from Saks Fifth Avenue in
Beverley Hills.

Twice an Academy
Award Nominated
actress

She had the following 8 drugs in
her possession:
Liquid demerol
 Liquid Diazepam
 Vicodin
 Percodan
 Valium
 Morphine sulfate
 Endocet (containing Oxycodone)


Patterns of Drug Use are highly
Regional.
 Drugs,

routes of administration, street
names, patterns of use, and drug
combinations may differ greatly, not
only between individuals from
different cultures, but different parts
of the country or even different parts
of the city.

Drugs of Choice
Native Americans-alcohol
 Asians-gambling, work
 Gay Men-stimulants, amyl nitrate, ecstasy
 “Rich”-prescription drugs, Internet porn
 M.D.’s –Vicodin


Drugs of Choice
Young adults-marijuana, cigarettes
 Geriatrics-alcohol, pills
 Sex Workers-crack cocaine, IV speedballs
 Screen mentally retarded for abuse too!


How Do We Best Serve Our
Consumers?




Examine own stereotypes.
Build trust.
Use People First language!

How do we best serve our
consumers?
Pronounce the person’s name correctly.
 Get an interpreter, if necessary.
 Educate yourself from the consumer, his
family, co-workers, etc.
 Remember differences do matter!



Slide 2

Cultural Competence
Integrating Differences
into Community Services

Objectives
Understand Stigma.
 Understand Culture Competency.
 Learn Culturally competent care for
people with Mental Health, Mental
Retardation and Addictions.


We live in an world
which often separates us.
Racism
 Sexism
 Ageism
 Feminism
 Classism
 Atheism


“Different” people are
“Stigmatized”

Mentally retarded inmates in a sanitorium in Germany

Stigma
Definitions from the U. of Chicago PSR Training Manual

“Stigmas are negative attitudes about a
group that lead to depriving them of
some fair opportunities.”

Stigma is related to…..
Stereotypes
Prejudice
Discrimination

Stereotypes
from The Asian Health Coalition of Illinois

Stereotypes are exaggerated beliefs
or fixed ideas about a person or
group which is held by people and
sustained by selective perception and
selective forgetting.

Prejudice
from The Asian Health Coalition of Illinois

Prejudice is a preconceived idea or
negative attitude formed before the
facts are known and sustained over
generalizations. A bias without
reason, resisting all evidence…

Discrimination
from The Asian Health Coalition of Illinois

Discrimination refers to treatment in
favor or against a person based on
the group to which that person
belongs and not on merit.

Stigmatized People…..
Experience being stereotyped and
are often the object of
discrimination and prejudice.

People are often stigmatized by:













Mental Illness
Mental Retardation
Physical Disability (including blindness, deafness)
Alcoholism /and or Drug Addiction
HIV or AIDS, Cancer or other terminal illnesses
Criminal behavior
Poverty
Alternative Lifestyles/sexual orientation
Wheelchair bound
Gender
Obesity

All our Consumers belong to
stigmatized groups!

Stigmatized People
Consumers and their families
can’t navigate the bureaucracy
even if resources are there.
It’s too frustrating!

Use People First Language
“I am more than my
illness….Don’t call me
“the schizophrenic,
“the addict” or
“the retard.”

As human beings, we have many
similarities…..
But, who we really are, is often
derived from our original family of origin
and our current lifestyle.

The Bottom Line:
People are different, even within
their own culture!
These differences matter when
planning and providing services.

National Mental Health
Association
“For Mental Health consumers, both
access to the services and the effectiveness
of the care they receive are greatly affected
by the degree to which the delivery system
is“culturally competent.”

Some important definitions
Related to Cultural Competency

Culture

from King,et. al

The Office of Special Programs, U.S. Dept. of Education

“The integrated patterns of human
behavior that includes thoughts,
communications, actions, customs,
beliefs,values, and institutions of
racial, ethnic, religious, or social
groups.”

Cultural Sensitivity
An awareness and respect of a
person’s cultural beliefs and
values.
Culhane-Pera, et .al

Cultural Competency
 Skills

(that translate into)
 Behaviors, Practices, Attitudes, and
 Policies
That enable an individual, agency, or
system to effectively serve culturally
diverse communities.
from The Asian Health Coalition of Illinois

Here at Hill Country MHDDC
Consumers are very diverse in their
language and culture.

61% of our Consumers are
Caucasian Americans
Many have German
backgrounds.

Our Consumers are …..

n
1% NativeAmerican

33% Hispanic
1% Asian

3% African
American

1% are “Others”

Consumers Have Many
Different Lifestyles

Lifestyles

They have many different
beliefs.

Can We Communicate?
Think Language first!
 Do we need an interpreter?
 Communicate respectfully.
 Be sensitive to the consumer and the family.
 Consider your dress, tone of voice, eye contact,
location, seating arrangement, privacy, etc.


Is our approach culturally
appropriate?
“What do you call your problem?”
“What name does it have?”
“What do you think caused your problem?”
“Why do you think it started when it did?”
From Arthur Kleinman’s question protocol in“Culture,Illness, and Care:
Clinical Lessons from Anthropologic and Cross Cultural Research”,
Ann.Intern.Med. 1978:Vol.88, pg.251-258

Important Issues to Consider…





Impact of religion.
How are women, men, elders, and children
treated in their culture?
Is there domestic violence?
Ethnic minorities generally underutilize
outpatient services, although African-Americans
are over-represented in inpatient setting.

Diagnosis






Minorities with Bipolar Disorder are often
diagnosed with schizophrenia. (Mukherjee,et al)
African Americans are over diagnosed with
schizophrenia and under diagnosed with mood
disorders. (Bell )
A mental health consumer’s addictions may not
be treated.
The elderly may not be assessed for substance
abuse or alcoholism.

Diagnosis
A person with a primary addiction problem
might not be treated for a co-occurring mental
illness.
 Learning disabilities may not be identified in
individuals with mental illness or substance
abuse.
 A person with mental retardation may not be
treated for mental illness or substance abuse.


Diagnosis
Post Traumatic Stress Disorder is often
undiagnosed in people suffering from
Domestic Abuse or other trauma.
 Children who are witnessing or are
victims of domestic abuse or another
trauma, may be misdiagnosed with
Attention Deficit Hyperactivity Disorder.


Medication Differences





Asians and Hispanics need lower doses of antipsychotics.
African Americans use the same doses of antipsychotics, but lower doses of lithium.
The elderly need lower dosages of medications.
Thus, metabolism of drugs varies with age and
ethnicity and is critical in prescribing
medications.

From “Making Room for Culture in Psychiatry” by Lin, et al.

Pain Tolerance
Men and women tolerate pain differently.
 Cultures tolerate pain differently.
 People with addictions develop a
hypersensitivity to pain.
 In certain cultures, self-inflicted pain is a
part of a religious experience.


Religion





Religious beliefs shape how the world is viewed.
Is illness a punishment? The devil’s work? An
evil spell? Bad karma?
For Hispanics, the curandero is a trusted healer.
For Lakota Sioux, the ritual Vision Quest,
praying and fasting at a holy site is life
changing.

Remember there are as many
differences
Between individuals in the same
culture as there are between
individuals in different cultures!

Two African American
families, one lesbian
and the other, multi-racial.

German Consumers
Suggestions from our Gillespie County MH staff

What generation German?
 Would they feel more comfortable
speaking in German?


A consumer reacting to internal stimuli.

German Consumers
Suggestions from our Gillespie MHC staff in Fredericksburg

They may be resistant to seeking
mental services.
They may be reluctant to take medication.
They may “keep things within the family.”
They are concerned about the stigma.

German Consumers
They may feel it’s a character flaw or a
disgrace.
 They are very concerned about
confidentiality.
 Drinking alcohol is an accepted part of
their culture.
 Teen drinking may be acceptable in their
family.


Hispanic Consumers
from the U.S. Census, 1/23/03 Houston Chronicle

Hispanics are the largest minority group in
the U.S. with 37 million people.
 Texas is approximately 32 percent
Hispanic
 11.5 % African American,
 3.3% Other
 53.1% Anglo


Treatment Issues for Hispanic
Consumers
Do we need an interpreter?
 Is the person Tejano or from Mexico?
What generation Hispanic?
Is the person using a curandero?

Treatment issues for Hispanic
Consumers
Hallucinations are natural in their
religion.
 Hearing the voice of a loved one or having
hallucinations might be an expectations
when celebrating the Day of the Dead.
 Hispanic families are patriarchal.


Hispanic Consumers and
The Day of the Dead
A man is dressed in a skeleton
costume to portray death
in a celebration of
Dia de los Muertos,
The Day of the Dead.
People visit the graves of their
dead relatives to honor them.

Native Americans

Treatment Issues for Native
American Consumers
 Impact of racism,unemployment,and poverty.
 Coping with reservation life and
assimilation in mainstream culture.
 Consider the obesity, diabetes,
hypertension, and alcoholism in adults
and fetal alcohol syndrome in children.
 High use of native healers in the Southwest.

African Americans

African Americans
from the Houston Chronicle, 1/23/03

There are 36.2 million Americans who
identify themselves as “black only.”
 37.7 million identify themselves as “black
and at least one other race.”
 11.5% of Texans are African Americans.


Treatment Issues for African
American
Assess for co-occurring substance use
disorders and alcoholism.
 Address complications of obesity,
hypertension, diabetes,congestive heart
failure, asthma, and cancer.
 Sickle cell anemia is another illness
specific to African Americans.


Treatment Issues for African
Americans
Matriarchy; Mom or grandmother are the
dominant family figures.
 Lack of male role models and intact
families.
 Extended family or the Church may be
supports.


Treatment Issues for African
Americans


There is discrimination within their own
group based on skin color, hair texture,
class, values, etc.

Treatment Issues for Asians

Asians rarely seek help until its very severe.
Asians have extremely low admissions to state hospitals.
Mental illness is considered shameful. It’s hidden.
Is an interpreter needed?

Treatment Issues for Asians
Focus on physical symptoms.
 Asians are sensitive to medication.
 Give ½ the standard dose.
 Asians may use traditional healers and
herbal medicine.
 Asians may “flush” when drinking
alcohol.


Asian Consumers

Acupuncture has been used to treat
pain, schizophrenia, depression, and addictions.

Treatment Issues for Asians
Asian Cultures are patriarchal.
 The males in the family have the authority.
 Asians are more formal and inhibited in
their social behavior.


Older Adults

Treatment Issues for Older
Adults
Are they aware they need help?

Treatment Issues for Older
Adults
Is their mental illness caused by medicine?
 Do their medical problems cause or
complicate their mental illness?
 Is there Elder Abuse?


Gay Men and Lesbian Women
May struggle with homophobia and“being in the
closet” at work and with their families.
Gay people may want marriage, children, partner
benefits, etc., but may endure legal barriers.

Gay and Lesbian Women
Gay people often have specific health
issues related to their sexual practices.
 HIV, AIDS and STD’s are still concerns
with Gay men.
 People may be grieving the death of a
partner or friends who’ve died from AIDS,
or coping with living with AIDS or being
HIV+ themselves.


Treatment Issues for Gay and
Lesbians
Explore childhood abuse issues and
Domestic Violence..
 Assess for substance use and alcoholism.
 Sex enhancing drug use may be common
among some gay men.


Physically Challenged
Can they get to treatment?
Deal with their frustration and depression
Re: their disability.
 Do they need vocational assistance?

Mentally Challenged

Treatment Issues of Mentally
Challenged
They need to have meaningful activity
and purpose in their lives.
 They need to feel acknowledged and
appreciated.
 They need safety, structure, and security.
 Lack of continuity can cause crisis!
 They may need vocational assistance.


Winona Ryder

December 12, 2001,
Winona Ryder shoplifted
$5,560.40 designer items
from Saks Fifth Avenue in
Beverley Hills.

Twice an Academy
Award Nominated
actress

She had the following 8 drugs in
her possession:
Liquid demerol
 Liquid Diazepam
 Vicodin
 Percodan
 Valium
 Morphine sulfate
 Endocet (containing Oxycodone)


Patterns of Drug Use are highly
Regional.
 Drugs,

routes of administration, street
names, patterns of use, and drug
combinations may differ greatly, not
only between individuals from
different cultures, but different parts
of the country or even different parts
of the city.

Drugs of Choice
Native Americans-alcohol
 Asians-gambling, work
 Gay Men-stimulants, amyl nitrate, ecstasy
 “Rich”-prescription drugs, Internet porn
 M.D.’s –Vicodin


Drugs of Choice
Young adults-marijuana, cigarettes
 Geriatrics-alcohol, pills
 Sex Workers-crack cocaine, IV speedballs
 Screen mentally retarded for abuse too!


How Do We Best Serve Our
Consumers?




Examine own stereotypes.
Build trust.
Use People First language!

How do we best serve our
consumers?
Pronounce the person’s name correctly.
 Get an interpreter, if necessary.
 Educate yourself from the consumer, his
family, co-workers, etc.
 Remember differences do matter!



Slide 3

Cultural Competence
Integrating Differences
into Community Services

Objectives
Understand Stigma.
 Understand Culture Competency.
 Learn Culturally competent care for
people with Mental Health, Mental
Retardation and Addictions.


We live in an world
which often separates us.
Racism
 Sexism
 Ageism
 Feminism
 Classism
 Atheism


“Different” people are
“Stigmatized”

Mentally retarded inmates in a sanitorium in Germany

Stigma
Definitions from the U. of Chicago PSR Training Manual

“Stigmas are negative attitudes about a
group that lead to depriving them of
some fair opportunities.”

Stigma is related to…..
Stereotypes
Prejudice
Discrimination

Stereotypes
from The Asian Health Coalition of Illinois

Stereotypes are exaggerated beliefs
or fixed ideas about a person or
group which is held by people and
sustained by selective perception and
selective forgetting.

Prejudice
from The Asian Health Coalition of Illinois

Prejudice is a preconceived idea or
negative attitude formed before the
facts are known and sustained over
generalizations. A bias without
reason, resisting all evidence…

Discrimination
from The Asian Health Coalition of Illinois

Discrimination refers to treatment in
favor or against a person based on
the group to which that person
belongs and not on merit.

Stigmatized People…..
Experience being stereotyped and
are often the object of
discrimination and prejudice.

People are often stigmatized by:













Mental Illness
Mental Retardation
Physical Disability (including blindness, deafness)
Alcoholism /and or Drug Addiction
HIV or AIDS, Cancer or other terminal illnesses
Criminal behavior
Poverty
Alternative Lifestyles/sexual orientation
Wheelchair bound
Gender
Obesity

All our Consumers belong to
stigmatized groups!

Stigmatized People
Consumers and their families
can’t navigate the bureaucracy
even if resources are there.
It’s too frustrating!

Use People First Language
“I am more than my
illness….Don’t call me
“the schizophrenic,
“the addict” or
“the retard.”

As human beings, we have many
similarities…..
But, who we really are, is often
derived from our original family of origin
and our current lifestyle.

The Bottom Line:
People are different, even within
their own culture!
These differences matter when
planning and providing services.

National Mental Health
Association
“For Mental Health consumers, both
access to the services and the effectiveness
of the care they receive are greatly affected
by the degree to which the delivery system
is“culturally competent.”

Some important definitions
Related to Cultural Competency

Culture

from King,et. al

The Office of Special Programs, U.S. Dept. of Education

“The integrated patterns of human
behavior that includes thoughts,
communications, actions, customs,
beliefs,values, and institutions of
racial, ethnic, religious, or social
groups.”

Cultural Sensitivity
An awareness and respect of a
person’s cultural beliefs and
values.
Culhane-Pera, et .al

Cultural Competency
 Skills

(that translate into)
 Behaviors, Practices, Attitudes, and
 Policies
That enable an individual, agency, or
system to effectively serve culturally
diverse communities.
from The Asian Health Coalition of Illinois

Here at Hill Country MHDDC
Consumers are very diverse in their
language and culture.

61% of our Consumers are
Caucasian Americans
Many have German
backgrounds.

Our Consumers are …..

n
1% NativeAmerican

33% Hispanic
1% Asian

3% African
American

1% are “Others”

Consumers Have Many
Different Lifestyles

Lifestyles

They have many different
beliefs.

Can We Communicate?
Think Language first!
 Do we need an interpreter?
 Communicate respectfully.
 Be sensitive to the consumer and the family.
 Consider your dress, tone of voice, eye contact,
location, seating arrangement, privacy, etc.


Is our approach culturally
appropriate?
“What do you call your problem?”
“What name does it have?”
“What do you think caused your problem?”
“Why do you think it started when it did?”
From Arthur Kleinman’s question protocol in“Culture,Illness, and Care:
Clinical Lessons from Anthropologic and Cross Cultural Research”,
Ann.Intern.Med. 1978:Vol.88, pg.251-258

Important Issues to Consider…





Impact of religion.
How are women, men, elders, and children
treated in their culture?
Is there domestic violence?
Ethnic minorities generally underutilize
outpatient services, although African-Americans
are over-represented in inpatient setting.

Diagnosis






Minorities with Bipolar Disorder are often
diagnosed with schizophrenia. (Mukherjee,et al)
African Americans are over diagnosed with
schizophrenia and under diagnosed with mood
disorders. (Bell )
A mental health consumer’s addictions may not
be treated.
The elderly may not be assessed for substance
abuse or alcoholism.

Diagnosis
A person with a primary addiction problem
might not be treated for a co-occurring mental
illness.
 Learning disabilities may not be identified in
individuals with mental illness or substance
abuse.
 A person with mental retardation may not be
treated for mental illness or substance abuse.


Diagnosis
Post Traumatic Stress Disorder is often
undiagnosed in people suffering from
Domestic Abuse or other trauma.
 Children who are witnessing or are
victims of domestic abuse or another
trauma, may be misdiagnosed with
Attention Deficit Hyperactivity Disorder.


Medication Differences





Asians and Hispanics need lower doses of antipsychotics.
African Americans use the same doses of antipsychotics, but lower doses of lithium.
The elderly need lower dosages of medications.
Thus, metabolism of drugs varies with age and
ethnicity and is critical in prescribing
medications.

From “Making Room for Culture in Psychiatry” by Lin, et al.

Pain Tolerance
Men and women tolerate pain differently.
 Cultures tolerate pain differently.
 People with addictions develop a
hypersensitivity to pain.
 In certain cultures, self-inflicted pain is a
part of a religious experience.


Religion





Religious beliefs shape how the world is viewed.
Is illness a punishment? The devil’s work? An
evil spell? Bad karma?
For Hispanics, the curandero is a trusted healer.
For Lakota Sioux, the ritual Vision Quest,
praying and fasting at a holy site is life
changing.

Remember there are as many
differences
Between individuals in the same
culture as there are between
individuals in different cultures!

Two African American
families, one lesbian
and the other, multi-racial.

German Consumers
Suggestions from our Gillespie County MH staff

What generation German?
 Would they feel more comfortable
speaking in German?


A consumer reacting to internal stimuli.

German Consumers
Suggestions from our Gillespie MHC staff in Fredericksburg

They may be resistant to seeking
mental services.
They may be reluctant to take medication.
They may “keep things within the family.”
They are concerned about the stigma.

German Consumers
They may feel it’s a character flaw or a
disgrace.
 They are very concerned about
confidentiality.
 Drinking alcohol is an accepted part of
their culture.
 Teen drinking may be acceptable in their
family.


Hispanic Consumers
from the U.S. Census, 1/23/03 Houston Chronicle

Hispanics are the largest minority group in
the U.S. with 37 million people.
 Texas is approximately 32 percent
Hispanic
 11.5 % African American,
 3.3% Other
 53.1% Anglo


Treatment Issues for Hispanic
Consumers
Do we need an interpreter?
 Is the person Tejano or from Mexico?
What generation Hispanic?
Is the person using a curandero?

Treatment issues for Hispanic
Consumers
Hallucinations are natural in their
religion.
 Hearing the voice of a loved one or having
hallucinations might be an expectations
when celebrating the Day of the Dead.
 Hispanic families are patriarchal.


Hispanic Consumers and
The Day of the Dead
A man is dressed in a skeleton
costume to portray death
in a celebration of
Dia de los Muertos,
The Day of the Dead.
People visit the graves of their
dead relatives to honor them.

Native Americans

Treatment Issues for Native
American Consumers
 Impact of racism,unemployment,and poverty.
 Coping with reservation life and
assimilation in mainstream culture.
 Consider the obesity, diabetes,
hypertension, and alcoholism in adults
and fetal alcohol syndrome in children.
 High use of native healers in the Southwest.

African Americans

African Americans
from the Houston Chronicle, 1/23/03

There are 36.2 million Americans who
identify themselves as “black only.”
 37.7 million identify themselves as “black
and at least one other race.”
 11.5% of Texans are African Americans.


Treatment Issues for African
American
Assess for co-occurring substance use
disorders and alcoholism.
 Address complications of obesity,
hypertension, diabetes,congestive heart
failure, asthma, and cancer.
 Sickle cell anemia is another illness
specific to African Americans.


Treatment Issues for African
Americans
Matriarchy; Mom or grandmother are the
dominant family figures.
 Lack of male role models and intact
families.
 Extended family or the Church may be
supports.


Treatment Issues for African
Americans


There is discrimination within their own
group based on skin color, hair texture,
class, values, etc.

Treatment Issues for Asians

Asians rarely seek help until its very severe.
Asians have extremely low admissions to state hospitals.
Mental illness is considered shameful. It’s hidden.
Is an interpreter needed?

Treatment Issues for Asians
Focus on physical symptoms.
 Asians are sensitive to medication.
 Give ½ the standard dose.
 Asians may use traditional healers and
herbal medicine.
 Asians may “flush” when drinking
alcohol.


Asian Consumers

Acupuncture has been used to treat
pain, schizophrenia, depression, and addictions.

Treatment Issues for Asians
Asian Cultures are patriarchal.
 The males in the family have the authority.
 Asians are more formal and inhibited in
their social behavior.


Older Adults

Treatment Issues for Older
Adults
Are they aware they need help?

Treatment Issues for Older
Adults
Is their mental illness caused by medicine?
 Do their medical problems cause or
complicate their mental illness?
 Is there Elder Abuse?


Gay Men and Lesbian Women
May struggle with homophobia and“being in the
closet” at work and with their families.
Gay people may want marriage, children, partner
benefits, etc., but may endure legal barriers.

Gay and Lesbian Women
Gay people often have specific health
issues related to their sexual practices.
 HIV, AIDS and STD’s are still concerns
with Gay men.
 People may be grieving the death of a
partner or friends who’ve died from AIDS,
or coping with living with AIDS or being
HIV+ themselves.


Treatment Issues for Gay and
Lesbians
Explore childhood abuse issues and
Domestic Violence..
 Assess for substance use and alcoholism.
 Sex enhancing drug use may be common
among some gay men.


Physically Challenged
Can they get to treatment?
Deal with their frustration and depression
Re: their disability.
 Do they need vocational assistance?

Mentally Challenged

Treatment Issues of Mentally
Challenged
They need to have meaningful activity
and purpose in their lives.
 They need to feel acknowledged and
appreciated.
 They need safety, structure, and security.
 Lack of continuity can cause crisis!
 They may need vocational assistance.


Winona Ryder

December 12, 2001,
Winona Ryder shoplifted
$5,560.40 designer items
from Saks Fifth Avenue in
Beverley Hills.

Twice an Academy
Award Nominated
actress

She had the following 8 drugs in
her possession:
Liquid demerol
 Liquid Diazepam
 Vicodin
 Percodan
 Valium
 Morphine sulfate
 Endocet (containing Oxycodone)


Patterns of Drug Use are highly
Regional.
 Drugs,

routes of administration, street
names, patterns of use, and drug
combinations may differ greatly, not
only between individuals from
different cultures, but different parts
of the country or even different parts
of the city.

Drugs of Choice
Native Americans-alcohol
 Asians-gambling, work
 Gay Men-stimulants, amyl nitrate, ecstasy
 “Rich”-prescription drugs, Internet porn
 M.D.’s –Vicodin


Drugs of Choice
Young adults-marijuana, cigarettes
 Geriatrics-alcohol, pills
 Sex Workers-crack cocaine, IV speedballs
 Screen mentally retarded for abuse too!


How Do We Best Serve Our
Consumers?




Examine own stereotypes.
Build trust.
Use People First language!

How do we best serve our
consumers?
Pronounce the person’s name correctly.
 Get an interpreter, if necessary.
 Educate yourself from the consumer, his
family, co-workers, etc.
 Remember differences do matter!



Slide 4

Cultural Competence
Integrating Differences
into Community Services

Objectives
Understand Stigma.
 Understand Culture Competency.
 Learn Culturally competent care for
people with Mental Health, Mental
Retardation and Addictions.


We live in an world
which often separates us.
Racism
 Sexism
 Ageism
 Feminism
 Classism
 Atheism


“Different” people are
“Stigmatized”

Mentally retarded inmates in a sanitorium in Germany

Stigma
Definitions from the U. of Chicago PSR Training Manual

“Stigmas are negative attitudes about a
group that lead to depriving them of
some fair opportunities.”

Stigma is related to…..
Stereotypes
Prejudice
Discrimination

Stereotypes
from The Asian Health Coalition of Illinois

Stereotypes are exaggerated beliefs
or fixed ideas about a person or
group which is held by people and
sustained by selective perception and
selective forgetting.

Prejudice
from The Asian Health Coalition of Illinois

Prejudice is a preconceived idea or
negative attitude formed before the
facts are known and sustained over
generalizations. A bias without
reason, resisting all evidence…

Discrimination
from The Asian Health Coalition of Illinois

Discrimination refers to treatment in
favor or against a person based on
the group to which that person
belongs and not on merit.

Stigmatized People…..
Experience being stereotyped and
are often the object of
discrimination and prejudice.

People are often stigmatized by:













Mental Illness
Mental Retardation
Physical Disability (including blindness, deafness)
Alcoholism /and or Drug Addiction
HIV or AIDS, Cancer or other terminal illnesses
Criminal behavior
Poverty
Alternative Lifestyles/sexual orientation
Wheelchair bound
Gender
Obesity

All our Consumers belong to
stigmatized groups!

Stigmatized People
Consumers and their families
can’t navigate the bureaucracy
even if resources are there.
It’s too frustrating!

Use People First Language
“I am more than my
illness….Don’t call me
“the schizophrenic,
“the addict” or
“the retard.”

As human beings, we have many
similarities…..
But, who we really are, is often
derived from our original family of origin
and our current lifestyle.

The Bottom Line:
People are different, even within
their own culture!
These differences matter when
planning and providing services.

National Mental Health
Association
“For Mental Health consumers, both
access to the services and the effectiveness
of the care they receive are greatly affected
by the degree to which the delivery system
is“culturally competent.”

Some important definitions
Related to Cultural Competency

Culture

from King,et. al

The Office of Special Programs, U.S. Dept. of Education

“The integrated patterns of human
behavior that includes thoughts,
communications, actions, customs,
beliefs,values, and institutions of
racial, ethnic, religious, or social
groups.”

Cultural Sensitivity
An awareness and respect of a
person’s cultural beliefs and
values.
Culhane-Pera, et .al

Cultural Competency
 Skills

(that translate into)
 Behaviors, Practices, Attitudes, and
 Policies
That enable an individual, agency, or
system to effectively serve culturally
diverse communities.
from The Asian Health Coalition of Illinois

Here at Hill Country MHDDC
Consumers are very diverse in their
language and culture.

61% of our Consumers are
Caucasian Americans
Many have German
backgrounds.

Our Consumers are …..

n
1% NativeAmerican

33% Hispanic
1% Asian

3% African
American

1% are “Others”

Consumers Have Many
Different Lifestyles

Lifestyles

They have many different
beliefs.

Can We Communicate?
Think Language first!
 Do we need an interpreter?
 Communicate respectfully.
 Be sensitive to the consumer and the family.
 Consider your dress, tone of voice, eye contact,
location, seating arrangement, privacy, etc.


Is our approach culturally
appropriate?
“What do you call your problem?”
“What name does it have?”
“What do you think caused your problem?”
“Why do you think it started when it did?”
From Arthur Kleinman’s question protocol in“Culture,Illness, and Care:
Clinical Lessons from Anthropologic and Cross Cultural Research”,
Ann.Intern.Med. 1978:Vol.88, pg.251-258

Important Issues to Consider…





Impact of religion.
How are women, men, elders, and children
treated in their culture?
Is there domestic violence?
Ethnic minorities generally underutilize
outpatient services, although African-Americans
are over-represented in inpatient setting.

Diagnosis






Minorities with Bipolar Disorder are often
diagnosed with schizophrenia. (Mukherjee,et al)
African Americans are over diagnosed with
schizophrenia and under diagnosed with mood
disorders. (Bell )
A mental health consumer’s addictions may not
be treated.
The elderly may not be assessed for substance
abuse or alcoholism.

Diagnosis
A person with a primary addiction problem
might not be treated for a co-occurring mental
illness.
 Learning disabilities may not be identified in
individuals with mental illness or substance
abuse.
 A person with mental retardation may not be
treated for mental illness or substance abuse.


Diagnosis
Post Traumatic Stress Disorder is often
undiagnosed in people suffering from
Domestic Abuse or other trauma.
 Children who are witnessing or are
victims of domestic abuse or another
trauma, may be misdiagnosed with
Attention Deficit Hyperactivity Disorder.


Medication Differences





Asians and Hispanics need lower doses of antipsychotics.
African Americans use the same doses of antipsychotics, but lower doses of lithium.
The elderly need lower dosages of medications.
Thus, metabolism of drugs varies with age and
ethnicity and is critical in prescribing
medications.

From “Making Room for Culture in Psychiatry” by Lin, et al.

Pain Tolerance
Men and women tolerate pain differently.
 Cultures tolerate pain differently.
 People with addictions develop a
hypersensitivity to pain.
 In certain cultures, self-inflicted pain is a
part of a religious experience.


Religion





Religious beliefs shape how the world is viewed.
Is illness a punishment? The devil’s work? An
evil spell? Bad karma?
For Hispanics, the curandero is a trusted healer.
For Lakota Sioux, the ritual Vision Quest,
praying and fasting at a holy site is life
changing.

Remember there are as many
differences
Between individuals in the same
culture as there are between
individuals in different cultures!

Two African American
families, one lesbian
and the other, multi-racial.

German Consumers
Suggestions from our Gillespie County MH staff

What generation German?
 Would they feel more comfortable
speaking in German?


A consumer reacting to internal stimuli.

German Consumers
Suggestions from our Gillespie MHC staff in Fredericksburg

They may be resistant to seeking
mental services.
They may be reluctant to take medication.
They may “keep things within the family.”
They are concerned about the stigma.

German Consumers
They may feel it’s a character flaw or a
disgrace.
 They are very concerned about
confidentiality.
 Drinking alcohol is an accepted part of
their culture.
 Teen drinking may be acceptable in their
family.


Hispanic Consumers
from the U.S. Census, 1/23/03 Houston Chronicle

Hispanics are the largest minority group in
the U.S. with 37 million people.
 Texas is approximately 32 percent
Hispanic
 11.5 % African American,
 3.3% Other
 53.1% Anglo


Treatment Issues for Hispanic
Consumers
Do we need an interpreter?
 Is the person Tejano or from Mexico?
What generation Hispanic?
Is the person using a curandero?

Treatment issues for Hispanic
Consumers
Hallucinations are natural in their
religion.
 Hearing the voice of a loved one or having
hallucinations might be an expectations
when celebrating the Day of the Dead.
 Hispanic families are patriarchal.


Hispanic Consumers and
The Day of the Dead
A man is dressed in a skeleton
costume to portray death
in a celebration of
Dia de los Muertos,
The Day of the Dead.
People visit the graves of their
dead relatives to honor them.

Native Americans

Treatment Issues for Native
American Consumers
 Impact of racism,unemployment,and poverty.
 Coping with reservation life and
assimilation in mainstream culture.
 Consider the obesity, diabetes,
hypertension, and alcoholism in adults
and fetal alcohol syndrome in children.
 High use of native healers in the Southwest.

African Americans

African Americans
from the Houston Chronicle, 1/23/03

There are 36.2 million Americans who
identify themselves as “black only.”
 37.7 million identify themselves as “black
and at least one other race.”
 11.5% of Texans are African Americans.


Treatment Issues for African
American
Assess for co-occurring substance use
disorders and alcoholism.
 Address complications of obesity,
hypertension, diabetes,congestive heart
failure, asthma, and cancer.
 Sickle cell anemia is another illness
specific to African Americans.


Treatment Issues for African
Americans
Matriarchy; Mom or grandmother are the
dominant family figures.
 Lack of male role models and intact
families.
 Extended family or the Church may be
supports.


Treatment Issues for African
Americans


There is discrimination within their own
group based on skin color, hair texture,
class, values, etc.

Treatment Issues for Asians

Asians rarely seek help until its very severe.
Asians have extremely low admissions to state hospitals.
Mental illness is considered shameful. It’s hidden.
Is an interpreter needed?

Treatment Issues for Asians
Focus on physical symptoms.
 Asians are sensitive to medication.
 Give ½ the standard dose.
 Asians may use traditional healers and
herbal medicine.
 Asians may “flush” when drinking
alcohol.


Asian Consumers

Acupuncture has been used to treat
pain, schizophrenia, depression, and addictions.

Treatment Issues for Asians
Asian Cultures are patriarchal.
 The males in the family have the authority.
 Asians are more formal and inhibited in
their social behavior.


Older Adults

Treatment Issues for Older
Adults
Are they aware they need help?

Treatment Issues for Older
Adults
Is their mental illness caused by medicine?
 Do their medical problems cause or
complicate their mental illness?
 Is there Elder Abuse?


Gay Men and Lesbian Women
May struggle with homophobia and“being in the
closet” at work and with their families.
Gay people may want marriage, children, partner
benefits, etc., but may endure legal barriers.

Gay and Lesbian Women
Gay people often have specific health
issues related to their sexual practices.
 HIV, AIDS and STD’s are still concerns
with Gay men.
 People may be grieving the death of a
partner or friends who’ve died from AIDS,
or coping with living with AIDS or being
HIV+ themselves.


Treatment Issues for Gay and
Lesbians
Explore childhood abuse issues and
Domestic Violence..
 Assess for substance use and alcoholism.
 Sex enhancing drug use may be common
among some gay men.


Physically Challenged
Can they get to treatment?
Deal with their frustration and depression
Re: their disability.
 Do they need vocational assistance?

Mentally Challenged

Treatment Issues of Mentally
Challenged
They need to have meaningful activity
and purpose in their lives.
 They need to feel acknowledged and
appreciated.
 They need safety, structure, and security.
 Lack of continuity can cause crisis!
 They may need vocational assistance.


Winona Ryder

December 12, 2001,
Winona Ryder shoplifted
$5,560.40 designer items
from Saks Fifth Avenue in
Beverley Hills.

Twice an Academy
Award Nominated
actress

She had the following 8 drugs in
her possession:
Liquid demerol
 Liquid Diazepam
 Vicodin
 Percodan
 Valium
 Morphine sulfate
 Endocet (containing Oxycodone)


Patterns of Drug Use are highly
Regional.
 Drugs,

routes of administration, street
names, patterns of use, and drug
combinations may differ greatly, not
only between individuals from
different cultures, but different parts
of the country or even different parts
of the city.

Drugs of Choice
Native Americans-alcohol
 Asians-gambling, work
 Gay Men-stimulants, amyl nitrate, ecstasy
 “Rich”-prescription drugs, Internet porn
 M.D.’s –Vicodin


Drugs of Choice
Young adults-marijuana, cigarettes
 Geriatrics-alcohol, pills
 Sex Workers-crack cocaine, IV speedballs
 Screen mentally retarded for abuse too!


How Do We Best Serve Our
Consumers?




Examine own stereotypes.
Build trust.
Use People First language!

How do we best serve our
consumers?
Pronounce the person’s name correctly.
 Get an interpreter, if necessary.
 Educate yourself from the consumer, his
family, co-workers, etc.
 Remember differences do matter!



Slide 5

Cultural Competence
Integrating Differences
into Community Services

Objectives
Understand Stigma.
 Understand Culture Competency.
 Learn Culturally competent care for
people with Mental Health, Mental
Retardation and Addictions.


We live in an world
which often separates us.
Racism
 Sexism
 Ageism
 Feminism
 Classism
 Atheism


“Different” people are
“Stigmatized”

Mentally retarded inmates in a sanitorium in Germany

Stigma
Definitions from the U. of Chicago PSR Training Manual

“Stigmas are negative attitudes about a
group that lead to depriving them of
some fair opportunities.”

Stigma is related to…..
Stereotypes
Prejudice
Discrimination

Stereotypes
from The Asian Health Coalition of Illinois

Stereotypes are exaggerated beliefs
or fixed ideas about a person or
group which is held by people and
sustained by selective perception and
selective forgetting.

Prejudice
from The Asian Health Coalition of Illinois

Prejudice is a preconceived idea or
negative attitude formed before the
facts are known and sustained over
generalizations. A bias without
reason, resisting all evidence…

Discrimination
from The Asian Health Coalition of Illinois

Discrimination refers to treatment in
favor or against a person based on
the group to which that person
belongs and not on merit.

Stigmatized People…..
Experience being stereotyped and
are often the object of
discrimination and prejudice.

People are often stigmatized by:













Mental Illness
Mental Retardation
Physical Disability (including blindness, deafness)
Alcoholism /and or Drug Addiction
HIV or AIDS, Cancer or other terminal illnesses
Criminal behavior
Poverty
Alternative Lifestyles/sexual orientation
Wheelchair bound
Gender
Obesity

All our Consumers belong to
stigmatized groups!

Stigmatized People
Consumers and their families
can’t navigate the bureaucracy
even if resources are there.
It’s too frustrating!

Use People First Language
“I am more than my
illness….Don’t call me
“the schizophrenic,
“the addict” or
“the retard.”

As human beings, we have many
similarities…..
But, who we really are, is often
derived from our original family of origin
and our current lifestyle.

The Bottom Line:
People are different, even within
their own culture!
These differences matter when
planning and providing services.

National Mental Health
Association
“For Mental Health consumers, both
access to the services and the effectiveness
of the care they receive are greatly affected
by the degree to which the delivery system
is“culturally competent.”

Some important definitions
Related to Cultural Competency

Culture

from King,et. al

The Office of Special Programs, U.S. Dept. of Education

“The integrated patterns of human
behavior that includes thoughts,
communications, actions, customs,
beliefs,values, and institutions of
racial, ethnic, religious, or social
groups.”

Cultural Sensitivity
An awareness and respect of a
person’s cultural beliefs and
values.
Culhane-Pera, et .al

Cultural Competency
 Skills

(that translate into)
 Behaviors, Practices, Attitudes, and
 Policies
That enable an individual, agency, or
system to effectively serve culturally
diverse communities.
from The Asian Health Coalition of Illinois

Here at Hill Country MHDDC
Consumers are very diverse in their
language and culture.

61% of our Consumers are
Caucasian Americans
Many have German
backgrounds.

Our Consumers are …..

n
1% NativeAmerican

33% Hispanic
1% Asian

3% African
American

1% are “Others”

Consumers Have Many
Different Lifestyles

Lifestyles

They have many different
beliefs.

Can We Communicate?
Think Language first!
 Do we need an interpreter?
 Communicate respectfully.
 Be sensitive to the consumer and the family.
 Consider your dress, tone of voice, eye contact,
location, seating arrangement, privacy, etc.


Is our approach culturally
appropriate?
“What do you call your problem?”
“What name does it have?”
“What do you think caused your problem?”
“Why do you think it started when it did?”
From Arthur Kleinman’s question protocol in“Culture,Illness, and Care:
Clinical Lessons from Anthropologic and Cross Cultural Research”,
Ann.Intern.Med. 1978:Vol.88, pg.251-258

Important Issues to Consider…





Impact of religion.
How are women, men, elders, and children
treated in their culture?
Is there domestic violence?
Ethnic minorities generally underutilize
outpatient services, although African-Americans
are over-represented in inpatient setting.

Diagnosis






Minorities with Bipolar Disorder are often
diagnosed with schizophrenia. (Mukherjee,et al)
African Americans are over diagnosed with
schizophrenia and under diagnosed with mood
disorders. (Bell )
A mental health consumer’s addictions may not
be treated.
The elderly may not be assessed for substance
abuse or alcoholism.

Diagnosis
A person with a primary addiction problem
might not be treated for a co-occurring mental
illness.
 Learning disabilities may not be identified in
individuals with mental illness or substance
abuse.
 A person with mental retardation may not be
treated for mental illness or substance abuse.


Diagnosis
Post Traumatic Stress Disorder is often
undiagnosed in people suffering from
Domestic Abuse or other trauma.
 Children who are witnessing or are
victims of domestic abuse or another
trauma, may be misdiagnosed with
Attention Deficit Hyperactivity Disorder.


Medication Differences





Asians and Hispanics need lower doses of antipsychotics.
African Americans use the same doses of antipsychotics, but lower doses of lithium.
The elderly need lower dosages of medications.
Thus, metabolism of drugs varies with age and
ethnicity and is critical in prescribing
medications.

From “Making Room for Culture in Psychiatry” by Lin, et al.

Pain Tolerance
Men and women tolerate pain differently.
 Cultures tolerate pain differently.
 People with addictions develop a
hypersensitivity to pain.
 In certain cultures, self-inflicted pain is a
part of a religious experience.


Religion





Religious beliefs shape how the world is viewed.
Is illness a punishment? The devil’s work? An
evil spell? Bad karma?
For Hispanics, the curandero is a trusted healer.
For Lakota Sioux, the ritual Vision Quest,
praying and fasting at a holy site is life
changing.

Remember there are as many
differences
Between individuals in the same
culture as there are between
individuals in different cultures!

Two African American
families, one lesbian
and the other, multi-racial.

German Consumers
Suggestions from our Gillespie County MH staff

What generation German?
 Would they feel more comfortable
speaking in German?


A consumer reacting to internal stimuli.

German Consumers
Suggestions from our Gillespie MHC staff in Fredericksburg

They may be resistant to seeking
mental services.
They may be reluctant to take medication.
They may “keep things within the family.”
They are concerned about the stigma.

German Consumers
They may feel it’s a character flaw or a
disgrace.
 They are very concerned about
confidentiality.
 Drinking alcohol is an accepted part of
their culture.
 Teen drinking may be acceptable in their
family.


Hispanic Consumers
from the U.S. Census, 1/23/03 Houston Chronicle

Hispanics are the largest minority group in
the U.S. with 37 million people.
 Texas is approximately 32 percent
Hispanic
 11.5 % African American,
 3.3% Other
 53.1% Anglo


Treatment Issues for Hispanic
Consumers
Do we need an interpreter?
 Is the person Tejano or from Mexico?
What generation Hispanic?
Is the person using a curandero?

Treatment issues for Hispanic
Consumers
Hallucinations are natural in their
religion.
 Hearing the voice of a loved one or having
hallucinations might be an expectations
when celebrating the Day of the Dead.
 Hispanic families are patriarchal.


Hispanic Consumers and
The Day of the Dead
A man is dressed in a skeleton
costume to portray death
in a celebration of
Dia de los Muertos,
The Day of the Dead.
People visit the graves of their
dead relatives to honor them.

Native Americans

Treatment Issues for Native
American Consumers
 Impact of racism,unemployment,and poverty.
 Coping with reservation life and
assimilation in mainstream culture.
 Consider the obesity, diabetes,
hypertension, and alcoholism in adults
and fetal alcohol syndrome in children.
 High use of native healers in the Southwest.

African Americans

African Americans
from the Houston Chronicle, 1/23/03

There are 36.2 million Americans who
identify themselves as “black only.”
 37.7 million identify themselves as “black
and at least one other race.”
 11.5% of Texans are African Americans.


Treatment Issues for African
American
Assess for co-occurring substance use
disorders and alcoholism.
 Address complications of obesity,
hypertension, diabetes,congestive heart
failure, asthma, and cancer.
 Sickle cell anemia is another illness
specific to African Americans.


Treatment Issues for African
Americans
Matriarchy; Mom or grandmother are the
dominant family figures.
 Lack of male role models and intact
families.
 Extended family or the Church may be
supports.


Treatment Issues for African
Americans


There is discrimination within their own
group based on skin color, hair texture,
class, values, etc.

Treatment Issues for Asians

Asians rarely seek help until its very severe.
Asians have extremely low admissions to state hospitals.
Mental illness is considered shameful. It’s hidden.
Is an interpreter needed?

Treatment Issues for Asians
Focus on physical symptoms.
 Asians are sensitive to medication.
 Give ½ the standard dose.
 Asians may use traditional healers and
herbal medicine.
 Asians may “flush” when drinking
alcohol.


Asian Consumers

Acupuncture has been used to treat
pain, schizophrenia, depression, and addictions.

Treatment Issues for Asians
Asian Cultures are patriarchal.
 The males in the family have the authority.
 Asians are more formal and inhibited in
their social behavior.


Older Adults

Treatment Issues for Older
Adults
Are they aware they need help?

Treatment Issues for Older
Adults
Is their mental illness caused by medicine?
 Do their medical problems cause or
complicate their mental illness?
 Is there Elder Abuse?


Gay Men and Lesbian Women
May struggle with homophobia and“being in the
closet” at work and with their families.
Gay people may want marriage, children, partner
benefits, etc., but may endure legal barriers.

Gay and Lesbian Women
Gay people often have specific health
issues related to their sexual practices.
 HIV, AIDS and STD’s are still concerns
with Gay men.
 People may be grieving the death of a
partner or friends who’ve died from AIDS,
or coping with living with AIDS or being
HIV+ themselves.


Treatment Issues for Gay and
Lesbians
Explore childhood abuse issues and
Domestic Violence..
 Assess for substance use and alcoholism.
 Sex enhancing drug use may be common
among some gay men.


Physically Challenged
Can they get to treatment?
Deal with their frustration and depression
Re: their disability.
 Do they need vocational assistance?

Mentally Challenged

Treatment Issues of Mentally
Challenged
They need to have meaningful activity
and purpose in their lives.
 They need to feel acknowledged and
appreciated.
 They need safety, structure, and security.
 Lack of continuity can cause crisis!
 They may need vocational assistance.


Winona Ryder

December 12, 2001,
Winona Ryder shoplifted
$5,560.40 designer items
from Saks Fifth Avenue in
Beverley Hills.

Twice an Academy
Award Nominated
actress

She had the following 8 drugs in
her possession:
Liquid demerol
 Liquid Diazepam
 Vicodin
 Percodan
 Valium
 Morphine sulfate
 Endocet (containing Oxycodone)


Patterns of Drug Use are highly
Regional.
 Drugs,

routes of administration, street
names, patterns of use, and drug
combinations may differ greatly, not
only between individuals from
different cultures, but different parts
of the country or even different parts
of the city.

Drugs of Choice
Native Americans-alcohol
 Asians-gambling, work
 Gay Men-stimulants, amyl nitrate, ecstasy
 “Rich”-prescription drugs, Internet porn
 M.D.’s –Vicodin


Drugs of Choice
Young adults-marijuana, cigarettes
 Geriatrics-alcohol, pills
 Sex Workers-crack cocaine, IV speedballs
 Screen mentally retarded for abuse too!


How Do We Best Serve Our
Consumers?




Examine own stereotypes.
Build trust.
Use People First language!

How do we best serve our
consumers?
Pronounce the person’s name correctly.
 Get an interpreter, if necessary.
 Educate yourself from the consumer, his
family, co-workers, etc.
 Remember differences do matter!



Slide 6

Cultural Competence
Integrating Differences
into Community Services

Objectives
Understand Stigma.
 Understand Culture Competency.
 Learn Culturally competent care for
people with Mental Health, Mental
Retardation and Addictions.


We live in an world
which often separates us.
Racism
 Sexism
 Ageism
 Feminism
 Classism
 Atheism


“Different” people are
“Stigmatized”

Mentally retarded inmates in a sanitorium in Germany

Stigma
Definitions from the U. of Chicago PSR Training Manual

“Stigmas are negative attitudes about a
group that lead to depriving them of
some fair opportunities.”

Stigma is related to…..
Stereotypes
Prejudice
Discrimination

Stereotypes
from The Asian Health Coalition of Illinois

Stereotypes are exaggerated beliefs
or fixed ideas about a person or
group which is held by people and
sustained by selective perception and
selective forgetting.

Prejudice
from The Asian Health Coalition of Illinois

Prejudice is a preconceived idea or
negative attitude formed before the
facts are known and sustained over
generalizations. A bias without
reason, resisting all evidence…

Discrimination
from The Asian Health Coalition of Illinois

Discrimination refers to treatment in
favor or against a person based on
the group to which that person
belongs and not on merit.

Stigmatized People…..
Experience being stereotyped and
are often the object of
discrimination and prejudice.

People are often stigmatized by:













Mental Illness
Mental Retardation
Physical Disability (including blindness, deafness)
Alcoholism /and or Drug Addiction
HIV or AIDS, Cancer or other terminal illnesses
Criminal behavior
Poverty
Alternative Lifestyles/sexual orientation
Wheelchair bound
Gender
Obesity

All our Consumers belong to
stigmatized groups!

Stigmatized People
Consumers and their families
can’t navigate the bureaucracy
even if resources are there.
It’s too frustrating!

Use People First Language
“I am more than my
illness….Don’t call me
“the schizophrenic,
“the addict” or
“the retard.”

As human beings, we have many
similarities…..
But, who we really are, is often
derived from our original family of origin
and our current lifestyle.

The Bottom Line:
People are different, even within
their own culture!
These differences matter when
planning and providing services.

National Mental Health
Association
“For Mental Health consumers, both
access to the services and the effectiveness
of the care they receive are greatly affected
by the degree to which the delivery system
is“culturally competent.”

Some important definitions
Related to Cultural Competency

Culture

from King,et. al

The Office of Special Programs, U.S. Dept. of Education

“The integrated patterns of human
behavior that includes thoughts,
communications, actions, customs,
beliefs,values, and institutions of
racial, ethnic, religious, or social
groups.”

Cultural Sensitivity
An awareness and respect of a
person’s cultural beliefs and
values.
Culhane-Pera, et .al

Cultural Competency
 Skills

(that translate into)
 Behaviors, Practices, Attitudes, and
 Policies
That enable an individual, agency, or
system to effectively serve culturally
diverse communities.
from The Asian Health Coalition of Illinois

Here at Hill Country MHDDC
Consumers are very diverse in their
language and culture.

61% of our Consumers are
Caucasian Americans
Many have German
backgrounds.

Our Consumers are …..

n
1% NativeAmerican

33% Hispanic
1% Asian

3% African
American

1% are “Others”

Consumers Have Many
Different Lifestyles

Lifestyles

They have many different
beliefs.

Can We Communicate?
Think Language first!
 Do we need an interpreter?
 Communicate respectfully.
 Be sensitive to the consumer and the family.
 Consider your dress, tone of voice, eye contact,
location, seating arrangement, privacy, etc.


Is our approach culturally
appropriate?
“What do you call your problem?”
“What name does it have?”
“What do you think caused your problem?”
“Why do you think it started when it did?”
From Arthur Kleinman’s question protocol in“Culture,Illness, and Care:
Clinical Lessons from Anthropologic and Cross Cultural Research”,
Ann.Intern.Med. 1978:Vol.88, pg.251-258

Important Issues to Consider…





Impact of religion.
How are women, men, elders, and children
treated in their culture?
Is there domestic violence?
Ethnic minorities generally underutilize
outpatient services, although African-Americans
are over-represented in inpatient setting.

Diagnosis






Minorities with Bipolar Disorder are often
diagnosed with schizophrenia. (Mukherjee,et al)
African Americans are over diagnosed with
schizophrenia and under diagnosed with mood
disorders. (Bell )
A mental health consumer’s addictions may not
be treated.
The elderly may not be assessed for substance
abuse or alcoholism.

Diagnosis
A person with a primary addiction problem
might not be treated for a co-occurring mental
illness.
 Learning disabilities may not be identified in
individuals with mental illness or substance
abuse.
 A person with mental retardation may not be
treated for mental illness or substance abuse.


Diagnosis
Post Traumatic Stress Disorder is often
undiagnosed in people suffering from
Domestic Abuse or other trauma.
 Children who are witnessing or are
victims of domestic abuse or another
trauma, may be misdiagnosed with
Attention Deficit Hyperactivity Disorder.


Medication Differences





Asians and Hispanics need lower doses of antipsychotics.
African Americans use the same doses of antipsychotics, but lower doses of lithium.
The elderly need lower dosages of medications.
Thus, metabolism of drugs varies with age and
ethnicity and is critical in prescribing
medications.

From “Making Room for Culture in Psychiatry” by Lin, et al.

Pain Tolerance
Men and women tolerate pain differently.
 Cultures tolerate pain differently.
 People with addictions develop a
hypersensitivity to pain.
 In certain cultures, self-inflicted pain is a
part of a religious experience.


Religion





Religious beliefs shape how the world is viewed.
Is illness a punishment? The devil’s work? An
evil spell? Bad karma?
For Hispanics, the curandero is a trusted healer.
For Lakota Sioux, the ritual Vision Quest,
praying and fasting at a holy site is life
changing.

Remember there are as many
differences
Between individuals in the same
culture as there are between
individuals in different cultures!

Two African American
families, one lesbian
and the other, multi-racial.

German Consumers
Suggestions from our Gillespie County MH staff

What generation German?
 Would they feel more comfortable
speaking in German?


A consumer reacting to internal stimuli.

German Consumers
Suggestions from our Gillespie MHC staff in Fredericksburg

They may be resistant to seeking
mental services.
They may be reluctant to take medication.
They may “keep things within the family.”
They are concerned about the stigma.

German Consumers
They may feel it’s a character flaw or a
disgrace.
 They are very concerned about
confidentiality.
 Drinking alcohol is an accepted part of
their culture.
 Teen drinking may be acceptable in their
family.


Hispanic Consumers
from the U.S. Census, 1/23/03 Houston Chronicle

Hispanics are the largest minority group in
the U.S. with 37 million people.
 Texas is approximately 32 percent
Hispanic
 11.5 % African American,
 3.3% Other
 53.1% Anglo


Treatment Issues for Hispanic
Consumers
Do we need an interpreter?
 Is the person Tejano or from Mexico?
What generation Hispanic?
Is the person using a curandero?

Treatment issues for Hispanic
Consumers
Hallucinations are natural in their
religion.
 Hearing the voice of a loved one or having
hallucinations might be an expectations
when celebrating the Day of the Dead.
 Hispanic families are patriarchal.


Hispanic Consumers and
The Day of the Dead
A man is dressed in a skeleton
costume to portray death
in a celebration of
Dia de los Muertos,
The Day of the Dead.
People visit the graves of their
dead relatives to honor them.

Native Americans

Treatment Issues for Native
American Consumers
 Impact of racism,unemployment,and poverty.
 Coping with reservation life and
assimilation in mainstream culture.
 Consider the obesity, diabetes,
hypertension, and alcoholism in adults
and fetal alcohol syndrome in children.
 High use of native healers in the Southwest.

African Americans

African Americans
from the Houston Chronicle, 1/23/03

There are 36.2 million Americans who
identify themselves as “black only.”
 37.7 million identify themselves as “black
and at least one other race.”
 11.5% of Texans are African Americans.


Treatment Issues for African
American
Assess for co-occurring substance use
disorders and alcoholism.
 Address complications of obesity,
hypertension, diabetes,congestive heart
failure, asthma, and cancer.
 Sickle cell anemia is another illness
specific to African Americans.


Treatment Issues for African
Americans
Matriarchy; Mom or grandmother are the
dominant family figures.
 Lack of male role models and intact
families.
 Extended family or the Church may be
supports.


Treatment Issues for African
Americans


There is discrimination within their own
group based on skin color, hair texture,
class, values, etc.

Treatment Issues for Asians

Asians rarely seek help until its very severe.
Asians have extremely low admissions to state hospitals.
Mental illness is considered shameful. It’s hidden.
Is an interpreter needed?

Treatment Issues for Asians
Focus on physical symptoms.
 Asians are sensitive to medication.
 Give ½ the standard dose.
 Asians may use traditional healers and
herbal medicine.
 Asians may “flush” when drinking
alcohol.


Asian Consumers

Acupuncture has been used to treat
pain, schizophrenia, depression, and addictions.

Treatment Issues for Asians
Asian Cultures are patriarchal.
 The males in the family have the authority.
 Asians are more formal and inhibited in
their social behavior.


Older Adults

Treatment Issues for Older
Adults
Are they aware they need help?

Treatment Issues for Older
Adults
Is their mental illness caused by medicine?
 Do their medical problems cause or
complicate their mental illness?
 Is there Elder Abuse?


Gay Men and Lesbian Women
May struggle with homophobia and“being in the
closet” at work and with their families.
Gay people may want marriage, children, partner
benefits, etc., but may endure legal barriers.

Gay and Lesbian Women
Gay people often have specific health
issues related to their sexual practices.
 HIV, AIDS and STD’s are still concerns
with Gay men.
 People may be grieving the death of a
partner or friends who’ve died from AIDS,
or coping with living with AIDS or being
HIV+ themselves.


Treatment Issues for Gay and
Lesbians
Explore childhood abuse issues and
Domestic Violence..
 Assess for substance use and alcoholism.
 Sex enhancing drug use may be common
among some gay men.


Physically Challenged
Can they get to treatment?
Deal with their frustration and depression
Re: their disability.
 Do they need vocational assistance?

Mentally Challenged

Treatment Issues of Mentally
Challenged
They need to have meaningful activity
and purpose in their lives.
 They need to feel acknowledged and
appreciated.
 They need safety, structure, and security.
 Lack of continuity can cause crisis!
 They may need vocational assistance.


Winona Ryder

December 12, 2001,
Winona Ryder shoplifted
$5,560.40 designer items
from Saks Fifth Avenue in
Beverley Hills.

Twice an Academy
Award Nominated
actress

She had the following 8 drugs in
her possession:
Liquid demerol
 Liquid Diazepam
 Vicodin
 Percodan
 Valium
 Morphine sulfate
 Endocet (containing Oxycodone)


Patterns of Drug Use are highly
Regional.
 Drugs,

routes of administration, street
names, patterns of use, and drug
combinations may differ greatly, not
only between individuals from
different cultures, but different parts
of the country or even different parts
of the city.

Drugs of Choice
Native Americans-alcohol
 Asians-gambling, work
 Gay Men-stimulants, amyl nitrate, ecstasy
 “Rich”-prescription drugs, Internet porn
 M.D.’s –Vicodin


Drugs of Choice
Young adults-marijuana, cigarettes
 Geriatrics-alcohol, pills
 Sex Workers-crack cocaine, IV speedballs
 Screen mentally retarded for abuse too!


How Do We Best Serve Our
Consumers?




Examine own stereotypes.
Build trust.
Use People First language!

How do we best serve our
consumers?
Pronounce the person’s name correctly.
 Get an interpreter, if necessary.
 Educate yourself from the consumer, his
family, co-workers, etc.
 Remember differences do matter!



Slide 7

Cultural Competence
Integrating Differences
into Community Services

Objectives
Understand Stigma.
 Understand Culture Competency.
 Learn Culturally competent care for
people with Mental Health, Mental
Retardation and Addictions.


We live in an world
which often separates us.
Racism
 Sexism
 Ageism
 Feminism
 Classism
 Atheism


“Different” people are
“Stigmatized”

Mentally retarded inmates in a sanitorium in Germany

Stigma
Definitions from the U. of Chicago PSR Training Manual

“Stigmas are negative attitudes about a
group that lead to depriving them of
some fair opportunities.”

Stigma is related to…..
Stereotypes
Prejudice
Discrimination

Stereotypes
from The Asian Health Coalition of Illinois

Stereotypes are exaggerated beliefs
or fixed ideas about a person or
group which is held by people and
sustained by selective perception and
selective forgetting.

Prejudice
from The Asian Health Coalition of Illinois

Prejudice is a preconceived idea or
negative attitude formed before the
facts are known and sustained over
generalizations. A bias without
reason, resisting all evidence…

Discrimination
from The Asian Health Coalition of Illinois

Discrimination refers to treatment in
favor or against a person based on
the group to which that person
belongs and not on merit.

Stigmatized People…..
Experience being stereotyped and
are often the object of
discrimination and prejudice.

People are often stigmatized by:













Mental Illness
Mental Retardation
Physical Disability (including blindness, deafness)
Alcoholism /and or Drug Addiction
HIV or AIDS, Cancer or other terminal illnesses
Criminal behavior
Poverty
Alternative Lifestyles/sexual orientation
Wheelchair bound
Gender
Obesity

All our Consumers belong to
stigmatized groups!

Stigmatized People
Consumers and their families
can’t navigate the bureaucracy
even if resources are there.
It’s too frustrating!

Use People First Language
“I am more than my
illness….Don’t call me
“the schizophrenic,
“the addict” or
“the retard.”

As human beings, we have many
similarities…..
But, who we really are, is often
derived from our original family of origin
and our current lifestyle.

The Bottom Line:
People are different, even within
their own culture!
These differences matter when
planning and providing services.

National Mental Health
Association
“For Mental Health consumers, both
access to the services and the effectiveness
of the care they receive are greatly affected
by the degree to which the delivery system
is“culturally competent.”

Some important definitions
Related to Cultural Competency

Culture

from King,et. al

The Office of Special Programs, U.S. Dept. of Education

“The integrated patterns of human
behavior that includes thoughts,
communications, actions, customs,
beliefs,values, and institutions of
racial, ethnic, religious, or social
groups.”

Cultural Sensitivity
An awareness and respect of a
person’s cultural beliefs and
values.
Culhane-Pera, et .al

Cultural Competency
 Skills

(that translate into)
 Behaviors, Practices, Attitudes, and
 Policies
That enable an individual, agency, or
system to effectively serve culturally
diverse communities.
from The Asian Health Coalition of Illinois

Here at Hill Country MHDDC
Consumers are very diverse in their
language and culture.

61% of our Consumers are
Caucasian Americans
Many have German
backgrounds.

Our Consumers are …..

n
1% NativeAmerican

33% Hispanic
1% Asian

3% African
American

1% are “Others”

Consumers Have Many
Different Lifestyles

Lifestyles

They have many different
beliefs.

Can We Communicate?
Think Language first!
 Do we need an interpreter?
 Communicate respectfully.
 Be sensitive to the consumer and the family.
 Consider your dress, tone of voice, eye contact,
location, seating arrangement, privacy, etc.


Is our approach culturally
appropriate?
“What do you call your problem?”
“What name does it have?”
“What do you think caused your problem?”
“Why do you think it started when it did?”
From Arthur Kleinman’s question protocol in“Culture,Illness, and Care:
Clinical Lessons from Anthropologic and Cross Cultural Research”,
Ann.Intern.Med. 1978:Vol.88, pg.251-258

Important Issues to Consider…





Impact of religion.
How are women, men, elders, and children
treated in their culture?
Is there domestic violence?
Ethnic minorities generally underutilize
outpatient services, although African-Americans
are over-represented in inpatient setting.

Diagnosis






Minorities with Bipolar Disorder are often
diagnosed with schizophrenia. (Mukherjee,et al)
African Americans are over diagnosed with
schizophrenia and under diagnosed with mood
disorders. (Bell )
A mental health consumer’s addictions may not
be treated.
The elderly may not be assessed for substance
abuse or alcoholism.

Diagnosis
A person with a primary addiction problem
might not be treated for a co-occurring mental
illness.
 Learning disabilities may not be identified in
individuals with mental illness or substance
abuse.
 A person with mental retardation may not be
treated for mental illness or substance abuse.


Diagnosis
Post Traumatic Stress Disorder is often
undiagnosed in people suffering from
Domestic Abuse or other trauma.
 Children who are witnessing or are
victims of domestic abuse or another
trauma, may be misdiagnosed with
Attention Deficit Hyperactivity Disorder.


Medication Differences





Asians and Hispanics need lower doses of antipsychotics.
African Americans use the same doses of antipsychotics, but lower doses of lithium.
The elderly need lower dosages of medications.
Thus, metabolism of drugs varies with age and
ethnicity and is critical in prescribing
medications.

From “Making Room for Culture in Psychiatry” by Lin, et al.

Pain Tolerance
Men and women tolerate pain differently.
 Cultures tolerate pain differently.
 People with addictions develop a
hypersensitivity to pain.
 In certain cultures, self-inflicted pain is a
part of a religious experience.


Religion





Religious beliefs shape how the world is viewed.
Is illness a punishment? The devil’s work? An
evil spell? Bad karma?
For Hispanics, the curandero is a trusted healer.
For Lakota Sioux, the ritual Vision Quest,
praying and fasting at a holy site is life
changing.

Remember there are as many
differences
Between individuals in the same
culture as there are between
individuals in different cultures!

Two African American
families, one lesbian
and the other, multi-racial.

German Consumers
Suggestions from our Gillespie County MH staff

What generation German?
 Would they feel more comfortable
speaking in German?


A consumer reacting to internal stimuli.

German Consumers
Suggestions from our Gillespie MHC staff in Fredericksburg

They may be resistant to seeking
mental services.
They may be reluctant to take medication.
They may “keep things within the family.”
They are concerned about the stigma.

German Consumers
They may feel it’s a character flaw or a
disgrace.
 They are very concerned about
confidentiality.
 Drinking alcohol is an accepted part of
their culture.
 Teen drinking may be acceptable in their
family.


Hispanic Consumers
from the U.S. Census, 1/23/03 Houston Chronicle

Hispanics are the largest minority group in
the U.S. with 37 million people.
 Texas is approximately 32 percent
Hispanic
 11.5 % African American,
 3.3% Other
 53.1% Anglo


Treatment Issues for Hispanic
Consumers
Do we need an interpreter?
 Is the person Tejano or from Mexico?
What generation Hispanic?
Is the person using a curandero?

Treatment issues for Hispanic
Consumers
Hallucinations are natural in their
religion.
 Hearing the voice of a loved one or having
hallucinations might be an expectations
when celebrating the Day of the Dead.
 Hispanic families are patriarchal.


Hispanic Consumers and
The Day of the Dead
A man is dressed in a skeleton
costume to portray death
in a celebration of
Dia de los Muertos,
The Day of the Dead.
People visit the graves of their
dead relatives to honor them.

Native Americans

Treatment Issues for Native
American Consumers
 Impact of racism,unemployment,and poverty.
 Coping with reservation life and
assimilation in mainstream culture.
 Consider the obesity, diabetes,
hypertension, and alcoholism in adults
and fetal alcohol syndrome in children.
 High use of native healers in the Southwest.

African Americans

African Americans
from the Houston Chronicle, 1/23/03

There are 36.2 million Americans who
identify themselves as “black only.”
 37.7 million identify themselves as “black
and at least one other race.”
 11.5% of Texans are African Americans.


Treatment Issues for African
American
Assess for co-occurring substance use
disorders and alcoholism.
 Address complications of obesity,
hypertension, diabetes,congestive heart
failure, asthma, and cancer.
 Sickle cell anemia is another illness
specific to African Americans.


Treatment Issues for African
Americans
Matriarchy; Mom or grandmother are the
dominant family figures.
 Lack of male role models and intact
families.
 Extended family or the Church may be
supports.


Treatment Issues for African
Americans


There is discrimination within their own
group based on skin color, hair texture,
class, values, etc.

Treatment Issues for Asians

Asians rarely seek help until its very severe.
Asians have extremely low admissions to state hospitals.
Mental illness is considered shameful. It’s hidden.
Is an interpreter needed?

Treatment Issues for Asians
Focus on physical symptoms.
 Asians are sensitive to medication.
 Give ½ the standard dose.
 Asians may use traditional healers and
herbal medicine.
 Asians may “flush” when drinking
alcohol.


Asian Consumers

Acupuncture has been used to treat
pain, schizophrenia, depression, and addictions.

Treatment Issues for Asians
Asian Cultures are patriarchal.
 The males in the family have the authority.
 Asians are more formal and inhibited in
their social behavior.


Older Adults

Treatment Issues for Older
Adults
Are they aware they need help?

Treatment Issues for Older
Adults
Is their mental illness caused by medicine?
 Do their medical problems cause or
complicate their mental illness?
 Is there Elder Abuse?


Gay Men and Lesbian Women
May struggle with homophobia and“being in the
closet” at work and with their families.
Gay people may want marriage, children, partner
benefits, etc., but may endure legal barriers.

Gay and Lesbian Women
Gay people often have specific health
issues related to their sexual practices.
 HIV, AIDS and STD’s are still concerns
with Gay men.
 People may be grieving the death of a
partner or friends who’ve died from AIDS,
or coping with living with AIDS or being
HIV+ themselves.


Treatment Issues for Gay and
Lesbians
Explore childhood abuse issues and
Domestic Violence..
 Assess for substance use and alcoholism.
 Sex enhancing drug use may be common
among some gay men.


Physically Challenged
Can they get to treatment?
Deal with their frustration and depression
Re: their disability.
 Do they need vocational assistance?

Mentally Challenged

Treatment Issues of Mentally
Challenged
They need to have meaningful activity
and purpose in their lives.
 They need to feel acknowledged and
appreciated.
 They need safety, structure, and security.
 Lack of continuity can cause crisis!
 They may need vocational assistance.


Winona Ryder

December 12, 2001,
Winona Ryder shoplifted
$5,560.40 designer items
from Saks Fifth Avenue in
Beverley Hills.

Twice an Academy
Award Nominated
actress

She had the following 8 drugs in
her possession:
Liquid demerol
 Liquid Diazepam
 Vicodin
 Percodan
 Valium
 Morphine sulfate
 Endocet (containing Oxycodone)


Patterns of Drug Use are highly
Regional.
 Drugs,

routes of administration, street
names, patterns of use, and drug
combinations may differ greatly, not
only between individuals from
different cultures, but different parts
of the country or even different parts
of the city.

Drugs of Choice
Native Americans-alcohol
 Asians-gambling, work
 Gay Men-stimulants, amyl nitrate, ecstasy
 “Rich”-prescription drugs, Internet porn
 M.D.’s –Vicodin


Drugs of Choice
Young adults-marijuana, cigarettes
 Geriatrics-alcohol, pills
 Sex Workers-crack cocaine, IV speedballs
 Screen mentally retarded for abuse too!


How Do We Best Serve Our
Consumers?




Examine own stereotypes.
Build trust.
Use People First language!

How do we best serve our
consumers?
Pronounce the person’s name correctly.
 Get an interpreter, if necessary.
 Educate yourself from the consumer, his
family, co-workers, etc.
 Remember differences do matter!



Slide 8

Cultural Competence
Integrating Differences
into Community Services

Objectives
Understand Stigma.
 Understand Culture Competency.
 Learn Culturally competent care for
people with Mental Health, Mental
Retardation and Addictions.


We live in an world
which often separates us.
Racism
 Sexism
 Ageism
 Feminism
 Classism
 Atheism


“Different” people are
“Stigmatized”

Mentally retarded inmates in a sanitorium in Germany

Stigma
Definitions from the U. of Chicago PSR Training Manual

“Stigmas are negative attitudes about a
group that lead to depriving them of
some fair opportunities.”

Stigma is related to…..
Stereotypes
Prejudice
Discrimination

Stereotypes
from The Asian Health Coalition of Illinois

Stereotypes are exaggerated beliefs
or fixed ideas about a person or
group which is held by people and
sustained by selective perception and
selective forgetting.

Prejudice
from The Asian Health Coalition of Illinois

Prejudice is a preconceived idea or
negative attitude formed before the
facts are known and sustained over
generalizations. A bias without
reason, resisting all evidence…

Discrimination
from The Asian Health Coalition of Illinois

Discrimination refers to treatment in
favor or against a person based on
the group to which that person
belongs and not on merit.

Stigmatized People…..
Experience being stereotyped and
are often the object of
discrimination and prejudice.

People are often stigmatized by:













Mental Illness
Mental Retardation
Physical Disability (including blindness, deafness)
Alcoholism /and or Drug Addiction
HIV or AIDS, Cancer or other terminal illnesses
Criminal behavior
Poverty
Alternative Lifestyles/sexual orientation
Wheelchair bound
Gender
Obesity

All our Consumers belong to
stigmatized groups!

Stigmatized People
Consumers and their families
can’t navigate the bureaucracy
even if resources are there.
It’s too frustrating!

Use People First Language
“I am more than my
illness….Don’t call me
“the schizophrenic,
“the addict” or
“the retard.”

As human beings, we have many
similarities…..
But, who we really are, is often
derived from our original family of origin
and our current lifestyle.

The Bottom Line:
People are different, even within
their own culture!
These differences matter when
planning and providing services.

National Mental Health
Association
“For Mental Health consumers, both
access to the services and the effectiveness
of the care they receive are greatly affected
by the degree to which the delivery system
is“culturally competent.”

Some important definitions
Related to Cultural Competency

Culture

from King,et. al

The Office of Special Programs, U.S. Dept. of Education

“The integrated patterns of human
behavior that includes thoughts,
communications, actions, customs,
beliefs,values, and institutions of
racial, ethnic, religious, or social
groups.”

Cultural Sensitivity
An awareness and respect of a
person’s cultural beliefs and
values.
Culhane-Pera, et .al

Cultural Competency
 Skills

(that translate into)
 Behaviors, Practices, Attitudes, and
 Policies
That enable an individual, agency, or
system to effectively serve culturally
diverse communities.
from The Asian Health Coalition of Illinois

Here at Hill Country MHDDC
Consumers are very diverse in their
language and culture.

61% of our Consumers are
Caucasian Americans
Many have German
backgrounds.

Our Consumers are …..

n
1% NativeAmerican

33% Hispanic
1% Asian

3% African
American

1% are “Others”

Consumers Have Many
Different Lifestyles

Lifestyles

They have many different
beliefs.

Can We Communicate?
Think Language first!
 Do we need an interpreter?
 Communicate respectfully.
 Be sensitive to the consumer and the family.
 Consider your dress, tone of voice, eye contact,
location, seating arrangement, privacy, etc.


Is our approach culturally
appropriate?
“What do you call your problem?”
“What name does it have?”
“What do you think caused your problem?”
“Why do you think it started when it did?”
From Arthur Kleinman’s question protocol in“Culture,Illness, and Care:
Clinical Lessons from Anthropologic and Cross Cultural Research”,
Ann.Intern.Med. 1978:Vol.88, pg.251-258

Important Issues to Consider…





Impact of religion.
How are women, men, elders, and children
treated in their culture?
Is there domestic violence?
Ethnic minorities generally underutilize
outpatient services, although African-Americans
are over-represented in inpatient setting.

Diagnosis






Minorities with Bipolar Disorder are often
diagnosed with schizophrenia. (Mukherjee,et al)
African Americans are over diagnosed with
schizophrenia and under diagnosed with mood
disorders. (Bell )
A mental health consumer’s addictions may not
be treated.
The elderly may not be assessed for substance
abuse or alcoholism.

Diagnosis
A person with a primary addiction problem
might not be treated for a co-occurring mental
illness.
 Learning disabilities may not be identified in
individuals with mental illness or substance
abuse.
 A person with mental retardation may not be
treated for mental illness or substance abuse.


Diagnosis
Post Traumatic Stress Disorder is often
undiagnosed in people suffering from
Domestic Abuse or other trauma.
 Children who are witnessing or are
victims of domestic abuse or another
trauma, may be misdiagnosed with
Attention Deficit Hyperactivity Disorder.


Medication Differences





Asians and Hispanics need lower doses of antipsychotics.
African Americans use the same doses of antipsychotics, but lower doses of lithium.
The elderly need lower dosages of medications.
Thus, metabolism of drugs varies with age and
ethnicity and is critical in prescribing
medications.

From “Making Room for Culture in Psychiatry” by Lin, et al.

Pain Tolerance
Men and women tolerate pain differently.
 Cultures tolerate pain differently.
 People with addictions develop a
hypersensitivity to pain.
 In certain cultures, self-inflicted pain is a
part of a religious experience.


Religion





Religious beliefs shape how the world is viewed.
Is illness a punishment? The devil’s work? An
evil spell? Bad karma?
For Hispanics, the curandero is a trusted healer.
For Lakota Sioux, the ritual Vision Quest,
praying and fasting at a holy site is life
changing.

Remember there are as many
differences
Between individuals in the same
culture as there are between
individuals in different cultures!

Two African American
families, one lesbian
and the other, multi-racial.

German Consumers
Suggestions from our Gillespie County MH staff

What generation German?
 Would they feel more comfortable
speaking in German?


A consumer reacting to internal stimuli.

German Consumers
Suggestions from our Gillespie MHC staff in Fredericksburg

They may be resistant to seeking
mental services.
They may be reluctant to take medication.
They may “keep things within the family.”
They are concerned about the stigma.

German Consumers
They may feel it’s a character flaw or a
disgrace.
 They are very concerned about
confidentiality.
 Drinking alcohol is an accepted part of
their culture.
 Teen drinking may be acceptable in their
family.


Hispanic Consumers
from the U.S. Census, 1/23/03 Houston Chronicle

Hispanics are the largest minority group in
the U.S. with 37 million people.
 Texas is approximately 32 percent
Hispanic
 11.5 % African American,
 3.3% Other
 53.1% Anglo


Treatment Issues for Hispanic
Consumers
Do we need an interpreter?
 Is the person Tejano or from Mexico?
What generation Hispanic?
Is the person using a curandero?

Treatment issues for Hispanic
Consumers
Hallucinations are natural in their
religion.
 Hearing the voice of a loved one or having
hallucinations might be an expectations
when celebrating the Day of the Dead.
 Hispanic families are patriarchal.


Hispanic Consumers and
The Day of the Dead
A man is dressed in a skeleton
costume to portray death
in a celebration of
Dia de los Muertos,
The Day of the Dead.
People visit the graves of their
dead relatives to honor them.

Native Americans

Treatment Issues for Native
American Consumers
 Impact of racism,unemployment,and poverty.
 Coping with reservation life and
assimilation in mainstream culture.
 Consider the obesity, diabetes,
hypertension, and alcoholism in adults
and fetal alcohol syndrome in children.
 High use of native healers in the Southwest.

African Americans

African Americans
from the Houston Chronicle, 1/23/03

There are 36.2 million Americans who
identify themselves as “black only.”
 37.7 million identify themselves as “black
and at least one other race.”
 11.5% of Texans are African Americans.


Treatment Issues for African
American
Assess for co-occurring substance use
disorders and alcoholism.
 Address complications of obesity,
hypertension, diabetes,congestive heart
failure, asthma, and cancer.
 Sickle cell anemia is another illness
specific to African Americans.


Treatment Issues for African
Americans
Matriarchy; Mom or grandmother are the
dominant family figures.
 Lack of male role models and intact
families.
 Extended family or the Church may be
supports.


Treatment Issues for African
Americans


There is discrimination within their own
group based on skin color, hair texture,
class, values, etc.

Treatment Issues for Asians

Asians rarely seek help until its very severe.
Asians have extremely low admissions to state hospitals.
Mental illness is considered shameful. It’s hidden.
Is an interpreter needed?

Treatment Issues for Asians
Focus on physical symptoms.
 Asians are sensitive to medication.
 Give ½ the standard dose.
 Asians may use traditional healers and
herbal medicine.
 Asians may “flush” when drinking
alcohol.


Asian Consumers

Acupuncture has been used to treat
pain, schizophrenia, depression, and addictions.

Treatment Issues for Asians
Asian Cultures are patriarchal.
 The males in the family have the authority.
 Asians are more formal and inhibited in
their social behavior.


Older Adults

Treatment Issues for Older
Adults
Are they aware they need help?

Treatment Issues for Older
Adults
Is their mental illness caused by medicine?
 Do their medical problems cause or
complicate their mental illness?
 Is there Elder Abuse?


Gay Men and Lesbian Women
May struggle with homophobia and“being in the
closet” at work and with their families.
Gay people may want marriage, children, partner
benefits, etc., but may endure legal barriers.

Gay and Lesbian Women
Gay people often have specific health
issues related to their sexual practices.
 HIV, AIDS and STD’s are still concerns
with Gay men.
 People may be grieving the death of a
partner or friends who’ve died from AIDS,
or coping with living with AIDS or being
HIV+ themselves.


Treatment Issues for Gay and
Lesbians
Explore childhood abuse issues and
Domestic Violence..
 Assess for substance use and alcoholism.
 Sex enhancing drug use may be common
among some gay men.


Physically Challenged
Can they get to treatment?
Deal with their frustration and depression
Re: their disability.
 Do they need vocational assistance?

Mentally Challenged

Treatment Issues of Mentally
Challenged
They need to have meaningful activity
and purpose in their lives.
 They need to feel acknowledged and
appreciated.
 They need safety, structure, and security.
 Lack of continuity can cause crisis!
 They may need vocational assistance.


Winona Ryder

December 12, 2001,
Winona Ryder shoplifted
$5,560.40 designer items
from Saks Fifth Avenue in
Beverley Hills.

Twice an Academy
Award Nominated
actress

She had the following 8 drugs in
her possession:
Liquid demerol
 Liquid Diazepam
 Vicodin
 Percodan
 Valium
 Morphine sulfate
 Endocet (containing Oxycodone)


Patterns of Drug Use are highly
Regional.
 Drugs,

routes of administration, street
names, patterns of use, and drug
combinations may differ greatly, not
only between individuals from
different cultures, but different parts
of the country or even different parts
of the city.

Drugs of Choice
Native Americans-alcohol
 Asians-gambling, work
 Gay Men-stimulants, amyl nitrate, ecstasy
 “Rich”-prescription drugs, Internet porn
 M.D.’s –Vicodin


Drugs of Choice
Young adults-marijuana, cigarettes
 Geriatrics-alcohol, pills
 Sex Workers-crack cocaine, IV speedballs
 Screen mentally retarded for abuse too!


How Do We Best Serve Our
Consumers?




Examine own stereotypes.
Build trust.
Use People First language!

How do we best serve our
consumers?
Pronounce the person’s name correctly.
 Get an interpreter, if necessary.
 Educate yourself from the consumer, his
family, co-workers, etc.
 Remember differences do matter!



Slide 9

Cultural Competence
Integrating Differences
into Community Services

Objectives
Understand Stigma.
 Understand Culture Competency.
 Learn Culturally competent care for
people with Mental Health, Mental
Retardation and Addictions.


We live in an world
which often separates us.
Racism
 Sexism
 Ageism
 Feminism
 Classism
 Atheism


“Different” people are
“Stigmatized”

Mentally retarded inmates in a sanitorium in Germany

Stigma
Definitions from the U. of Chicago PSR Training Manual

“Stigmas are negative attitudes about a
group that lead to depriving them of
some fair opportunities.”

Stigma is related to…..
Stereotypes
Prejudice
Discrimination

Stereotypes
from The Asian Health Coalition of Illinois

Stereotypes are exaggerated beliefs
or fixed ideas about a person or
group which is held by people and
sustained by selective perception and
selective forgetting.

Prejudice
from The Asian Health Coalition of Illinois

Prejudice is a preconceived idea or
negative attitude formed before the
facts are known and sustained over
generalizations. A bias without
reason, resisting all evidence…

Discrimination
from The Asian Health Coalition of Illinois

Discrimination refers to treatment in
favor or against a person based on
the group to which that person
belongs and not on merit.

Stigmatized People…..
Experience being stereotyped and
are often the object of
discrimination and prejudice.

People are often stigmatized by:













Mental Illness
Mental Retardation
Physical Disability (including blindness, deafness)
Alcoholism /and or Drug Addiction
HIV or AIDS, Cancer or other terminal illnesses
Criminal behavior
Poverty
Alternative Lifestyles/sexual orientation
Wheelchair bound
Gender
Obesity

All our Consumers belong to
stigmatized groups!

Stigmatized People
Consumers and their families
can’t navigate the bureaucracy
even if resources are there.
It’s too frustrating!

Use People First Language
“I am more than my
illness….Don’t call me
“the schizophrenic,
“the addict” or
“the retard.”

As human beings, we have many
similarities…..
But, who we really are, is often
derived from our original family of origin
and our current lifestyle.

The Bottom Line:
People are different, even within
their own culture!
These differences matter when
planning and providing services.

National Mental Health
Association
“For Mental Health consumers, both
access to the services and the effectiveness
of the care they receive are greatly affected
by the degree to which the delivery system
is“culturally competent.”

Some important definitions
Related to Cultural Competency

Culture

from King,et. al

The Office of Special Programs, U.S. Dept. of Education

“The integrated patterns of human
behavior that includes thoughts,
communications, actions, customs,
beliefs,values, and institutions of
racial, ethnic, religious, or social
groups.”

Cultural Sensitivity
An awareness and respect of a
person’s cultural beliefs and
values.
Culhane-Pera, et .al

Cultural Competency
 Skills

(that translate into)
 Behaviors, Practices, Attitudes, and
 Policies
That enable an individual, agency, or
system to effectively serve culturally
diverse communities.
from The Asian Health Coalition of Illinois

Here at Hill Country MHDDC
Consumers are very diverse in their
language and culture.

61% of our Consumers are
Caucasian Americans
Many have German
backgrounds.

Our Consumers are …..

n
1% NativeAmerican

33% Hispanic
1% Asian

3% African
American

1% are “Others”

Consumers Have Many
Different Lifestyles

Lifestyles

They have many different
beliefs.

Can We Communicate?
Think Language first!
 Do we need an interpreter?
 Communicate respectfully.
 Be sensitive to the consumer and the family.
 Consider your dress, tone of voice, eye contact,
location, seating arrangement, privacy, etc.


Is our approach culturally
appropriate?
“What do you call your problem?”
“What name does it have?”
“What do you think caused your problem?”
“Why do you think it started when it did?”
From Arthur Kleinman’s question protocol in“Culture,Illness, and Care:
Clinical Lessons from Anthropologic and Cross Cultural Research”,
Ann.Intern.Med. 1978:Vol.88, pg.251-258

Important Issues to Consider…





Impact of religion.
How are women, men, elders, and children
treated in their culture?
Is there domestic violence?
Ethnic minorities generally underutilize
outpatient services, although African-Americans
are over-represented in inpatient setting.

Diagnosis






Minorities with Bipolar Disorder are often
diagnosed with schizophrenia. (Mukherjee,et al)
African Americans are over diagnosed with
schizophrenia and under diagnosed with mood
disorders. (Bell )
A mental health consumer’s addictions may not
be treated.
The elderly may not be assessed for substance
abuse or alcoholism.

Diagnosis
A person with a primary addiction problem
might not be treated for a co-occurring mental
illness.
 Learning disabilities may not be identified in
individuals with mental illness or substance
abuse.
 A person with mental retardation may not be
treated for mental illness or substance abuse.


Diagnosis
Post Traumatic Stress Disorder is often
undiagnosed in people suffering from
Domestic Abuse or other trauma.
 Children who are witnessing or are
victims of domestic abuse or another
trauma, may be misdiagnosed with
Attention Deficit Hyperactivity Disorder.


Medication Differences





Asians and Hispanics need lower doses of antipsychotics.
African Americans use the same doses of antipsychotics, but lower doses of lithium.
The elderly need lower dosages of medications.
Thus, metabolism of drugs varies with age and
ethnicity and is critical in prescribing
medications.

From “Making Room for Culture in Psychiatry” by Lin, et al.

Pain Tolerance
Men and women tolerate pain differently.
 Cultures tolerate pain differently.
 People with addictions develop a
hypersensitivity to pain.
 In certain cultures, self-inflicted pain is a
part of a religious experience.


Religion





Religious beliefs shape how the world is viewed.
Is illness a punishment? The devil’s work? An
evil spell? Bad karma?
For Hispanics, the curandero is a trusted healer.
For Lakota Sioux, the ritual Vision Quest,
praying and fasting at a holy site is life
changing.

Remember there are as many
differences
Between individuals in the same
culture as there are between
individuals in different cultures!

Two African American
families, one lesbian
and the other, multi-racial.

German Consumers
Suggestions from our Gillespie County MH staff

What generation German?
 Would they feel more comfortable
speaking in German?


A consumer reacting to internal stimuli.

German Consumers
Suggestions from our Gillespie MHC staff in Fredericksburg

They may be resistant to seeking
mental services.
They may be reluctant to take medication.
They may “keep things within the family.”
They are concerned about the stigma.

German Consumers
They may feel it’s a character flaw or a
disgrace.
 They are very concerned about
confidentiality.
 Drinking alcohol is an accepted part of
their culture.
 Teen drinking may be acceptable in their
family.


Hispanic Consumers
from the U.S. Census, 1/23/03 Houston Chronicle

Hispanics are the largest minority group in
the U.S. with 37 million people.
 Texas is approximately 32 percent
Hispanic
 11.5 % African American,
 3.3% Other
 53.1% Anglo


Treatment Issues for Hispanic
Consumers
Do we need an interpreter?
 Is the person Tejano or from Mexico?
What generation Hispanic?
Is the person using a curandero?

Treatment issues for Hispanic
Consumers
Hallucinations are natural in their
religion.
 Hearing the voice of a loved one or having
hallucinations might be an expectations
when celebrating the Day of the Dead.
 Hispanic families are patriarchal.


Hispanic Consumers and
The Day of the Dead
A man is dressed in a skeleton
costume to portray death
in a celebration of
Dia de los Muertos,
The Day of the Dead.
People visit the graves of their
dead relatives to honor them.

Native Americans

Treatment Issues for Native
American Consumers
 Impact of racism,unemployment,and poverty.
 Coping with reservation life and
assimilation in mainstream culture.
 Consider the obesity, diabetes,
hypertension, and alcoholism in adults
and fetal alcohol syndrome in children.
 High use of native healers in the Southwest.

African Americans

African Americans
from the Houston Chronicle, 1/23/03

There are 36.2 million Americans who
identify themselves as “black only.”
 37.7 million identify themselves as “black
and at least one other race.”
 11.5% of Texans are African Americans.


Treatment Issues for African
American
Assess for co-occurring substance use
disorders and alcoholism.
 Address complications of obesity,
hypertension, diabetes,congestive heart
failure, asthma, and cancer.
 Sickle cell anemia is another illness
specific to African Americans.


Treatment Issues for African
Americans
Matriarchy; Mom or grandmother are the
dominant family figures.
 Lack of male role models and intact
families.
 Extended family or the Church may be
supports.


Treatment Issues for African
Americans


There is discrimination within their own
group based on skin color, hair texture,
class, values, etc.

Treatment Issues for Asians

Asians rarely seek help until its very severe.
Asians have extremely low admissions to state hospitals.
Mental illness is considered shameful. It’s hidden.
Is an interpreter needed?

Treatment Issues for Asians
Focus on physical symptoms.
 Asians are sensitive to medication.
 Give ½ the standard dose.
 Asians may use traditional healers and
herbal medicine.
 Asians may “flush” when drinking
alcohol.


Asian Consumers

Acupuncture has been used to treat
pain, schizophrenia, depression, and addictions.

Treatment Issues for Asians
Asian Cultures are patriarchal.
 The males in the family have the authority.
 Asians are more formal and inhibited in
their social behavior.


Older Adults

Treatment Issues for Older
Adults
Are they aware they need help?

Treatment Issues for Older
Adults
Is their mental illness caused by medicine?
 Do their medical problems cause or
complicate their mental illness?
 Is there Elder Abuse?


Gay Men and Lesbian Women
May struggle with homophobia and“being in the
closet” at work and with their families.
Gay people may want marriage, children, partner
benefits, etc., but may endure legal barriers.

Gay and Lesbian Women
Gay people often have specific health
issues related to their sexual practices.
 HIV, AIDS and STD’s are still concerns
with Gay men.
 People may be grieving the death of a
partner or friends who’ve died from AIDS,
or coping with living with AIDS or being
HIV+ themselves.


Treatment Issues for Gay and
Lesbians
Explore childhood abuse issues and
Domestic Violence..
 Assess for substance use and alcoholism.
 Sex enhancing drug use may be common
among some gay men.


Physically Challenged
Can they get to treatment?
Deal with their frustration and depression
Re: their disability.
 Do they need vocational assistance?

Mentally Challenged

Treatment Issues of Mentally
Challenged
They need to have meaningful activity
and purpose in their lives.
 They need to feel acknowledged and
appreciated.
 They need safety, structure, and security.
 Lack of continuity can cause crisis!
 They may need vocational assistance.


Winona Ryder

December 12, 2001,
Winona Ryder shoplifted
$5,560.40 designer items
from Saks Fifth Avenue in
Beverley Hills.

Twice an Academy
Award Nominated
actress

She had the following 8 drugs in
her possession:
Liquid demerol
 Liquid Diazepam
 Vicodin
 Percodan
 Valium
 Morphine sulfate
 Endocet (containing Oxycodone)


Patterns of Drug Use are highly
Regional.
 Drugs,

routes of administration, street
names, patterns of use, and drug
combinations may differ greatly, not
only between individuals from
different cultures, but different parts
of the country or even different parts
of the city.

Drugs of Choice
Native Americans-alcohol
 Asians-gambling, work
 Gay Men-stimulants, amyl nitrate, ecstasy
 “Rich”-prescription drugs, Internet porn
 M.D.’s –Vicodin


Drugs of Choice
Young adults-marijuana, cigarettes
 Geriatrics-alcohol, pills
 Sex Workers-crack cocaine, IV speedballs
 Screen mentally retarded for abuse too!


How Do We Best Serve Our
Consumers?




Examine own stereotypes.
Build trust.
Use People First language!

How do we best serve our
consumers?
Pronounce the person’s name correctly.
 Get an interpreter, if necessary.
 Educate yourself from the consumer, his
family, co-workers, etc.
 Remember differences do matter!



Slide 10

Cultural Competence
Integrating Differences
into Community Services

Objectives
Understand Stigma.
 Understand Culture Competency.
 Learn Culturally competent care for
people with Mental Health, Mental
Retardation and Addictions.


We live in an world
which often separates us.
Racism
 Sexism
 Ageism
 Feminism
 Classism
 Atheism


“Different” people are
“Stigmatized”

Mentally retarded inmates in a sanitorium in Germany

Stigma
Definitions from the U. of Chicago PSR Training Manual

“Stigmas are negative attitudes about a
group that lead to depriving them of
some fair opportunities.”

Stigma is related to…..
Stereotypes
Prejudice
Discrimination

Stereotypes
from The Asian Health Coalition of Illinois

Stereotypes are exaggerated beliefs
or fixed ideas about a person or
group which is held by people and
sustained by selective perception and
selective forgetting.

Prejudice
from The Asian Health Coalition of Illinois

Prejudice is a preconceived idea or
negative attitude formed before the
facts are known and sustained over
generalizations. A bias without
reason, resisting all evidence…

Discrimination
from The Asian Health Coalition of Illinois

Discrimination refers to treatment in
favor or against a person based on
the group to which that person
belongs and not on merit.

Stigmatized People…..
Experience being stereotyped and
are often the object of
discrimination and prejudice.

People are often stigmatized by:













Mental Illness
Mental Retardation
Physical Disability (including blindness, deafness)
Alcoholism /and or Drug Addiction
HIV or AIDS, Cancer or other terminal illnesses
Criminal behavior
Poverty
Alternative Lifestyles/sexual orientation
Wheelchair bound
Gender
Obesity

All our Consumers belong to
stigmatized groups!

Stigmatized People
Consumers and their families
can’t navigate the bureaucracy
even if resources are there.
It’s too frustrating!

Use People First Language
“I am more than my
illness….Don’t call me
“the schizophrenic,
“the addict” or
“the retard.”

As human beings, we have many
similarities…..
But, who we really are, is often
derived from our original family of origin
and our current lifestyle.

The Bottom Line:
People are different, even within
their own culture!
These differences matter when
planning and providing services.

National Mental Health
Association
“For Mental Health consumers, both
access to the services and the effectiveness
of the care they receive are greatly affected
by the degree to which the delivery system
is“culturally competent.”

Some important definitions
Related to Cultural Competency

Culture

from King,et. al

The Office of Special Programs, U.S. Dept. of Education

“The integrated patterns of human
behavior that includes thoughts,
communications, actions, customs,
beliefs,values, and institutions of
racial, ethnic, religious, or social
groups.”

Cultural Sensitivity
An awareness and respect of a
person’s cultural beliefs and
values.
Culhane-Pera, et .al

Cultural Competency
 Skills

(that translate into)
 Behaviors, Practices, Attitudes, and
 Policies
That enable an individual, agency, or
system to effectively serve culturally
diverse communities.
from The Asian Health Coalition of Illinois

Here at Hill Country MHDDC
Consumers are very diverse in their
language and culture.

61% of our Consumers are
Caucasian Americans
Many have German
backgrounds.

Our Consumers are …..

n
1% NativeAmerican

33% Hispanic
1% Asian

3% African
American

1% are “Others”

Consumers Have Many
Different Lifestyles

Lifestyles

They have many different
beliefs.

Can We Communicate?
Think Language first!
 Do we need an interpreter?
 Communicate respectfully.
 Be sensitive to the consumer and the family.
 Consider your dress, tone of voice, eye contact,
location, seating arrangement, privacy, etc.


Is our approach culturally
appropriate?
“What do you call your problem?”
“What name does it have?”
“What do you think caused your problem?”
“Why do you think it started when it did?”
From Arthur Kleinman’s question protocol in“Culture,Illness, and Care:
Clinical Lessons from Anthropologic and Cross Cultural Research”,
Ann.Intern.Med. 1978:Vol.88, pg.251-258

Important Issues to Consider…





Impact of religion.
How are women, men, elders, and children
treated in their culture?
Is there domestic violence?
Ethnic minorities generally underutilize
outpatient services, although African-Americans
are over-represented in inpatient setting.

Diagnosis






Minorities with Bipolar Disorder are often
diagnosed with schizophrenia. (Mukherjee,et al)
African Americans are over diagnosed with
schizophrenia and under diagnosed with mood
disorders. (Bell )
A mental health consumer’s addictions may not
be treated.
The elderly may not be assessed for substance
abuse or alcoholism.

Diagnosis
A person with a primary addiction problem
might not be treated for a co-occurring mental
illness.
 Learning disabilities may not be identified in
individuals with mental illness or substance
abuse.
 A person with mental retardation may not be
treated for mental illness or substance abuse.


Diagnosis
Post Traumatic Stress Disorder is often
undiagnosed in people suffering from
Domestic Abuse or other trauma.
 Children who are witnessing or are
victims of domestic abuse or another
trauma, may be misdiagnosed with
Attention Deficit Hyperactivity Disorder.


Medication Differences





Asians and Hispanics need lower doses of antipsychotics.
African Americans use the same doses of antipsychotics, but lower doses of lithium.
The elderly need lower dosages of medications.
Thus, metabolism of drugs varies with age and
ethnicity and is critical in prescribing
medications.

From “Making Room for Culture in Psychiatry” by Lin, et al.

Pain Tolerance
Men and women tolerate pain differently.
 Cultures tolerate pain differently.
 People with addictions develop a
hypersensitivity to pain.
 In certain cultures, self-inflicted pain is a
part of a religious experience.


Religion





Religious beliefs shape how the world is viewed.
Is illness a punishment? The devil’s work? An
evil spell? Bad karma?
For Hispanics, the curandero is a trusted healer.
For Lakota Sioux, the ritual Vision Quest,
praying and fasting at a holy site is life
changing.

Remember there are as many
differences
Between individuals in the same
culture as there are between
individuals in different cultures!

Two African American
families, one lesbian
and the other, multi-racial.

German Consumers
Suggestions from our Gillespie County MH staff

What generation German?
 Would they feel more comfortable
speaking in German?


A consumer reacting to internal stimuli.

German Consumers
Suggestions from our Gillespie MHC staff in Fredericksburg

They may be resistant to seeking
mental services.
They may be reluctant to take medication.
They may “keep things within the family.”
They are concerned about the stigma.

German Consumers
They may feel it’s a character flaw or a
disgrace.
 They are very concerned about
confidentiality.
 Drinking alcohol is an accepted part of
their culture.
 Teen drinking may be acceptable in their
family.


Hispanic Consumers
from the U.S. Census, 1/23/03 Houston Chronicle

Hispanics are the largest minority group in
the U.S. with 37 million people.
 Texas is approximately 32 percent
Hispanic
 11.5 % African American,
 3.3% Other
 53.1% Anglo


Treatment Issues for Hispanic
Consumers
Do we need an interpreter?
 Is the person Tejano or from Mexico?
What generation Hispanic?
Is the person using a curandero?

Treatment issues for Hispanic
Consumers
Hallucinations are natural in their
religion.
 Hearing the voice of a loved one or having
hallucinations might be an expectations
when celebrating the Day of the Dead.
 Hispanic families are patriarchal.


Hispanic Consumers and
The Day of the Dead
A man is dressed in a skeleton
costume to portray death
in a celebration of
Dia de los Muertos,
The Day of the Dead.
People visit the graves of their
dead relatives to honor them.

Native Americans

Treatment Issues for Native
American Consumers
 Impact of racism,unemployment,and poverty.
 Coping with reservation life and
assimilation in mainstream culture.
 Consider the obesity, diabetes,
hypertension, and alcoholism in adults
and fetal alcohol syndrome in children.
 High use of native healers in the Southwest.

African Americans

African Americans
from the Houston Chronicle, 1/23/03

There are 36.2 million Americans who
identify themselves as “black only.”
 37.7 million identify themselves as “black
and at least one other race.”
 11.5% of Texans are African Americans.


Treatment Issues for African
American
Assess for co-occurring substance use
disorders and alcoholism.
 Address complications of obesity,
hypertension, diabetes,congestive heart
failure, asthma, and cancer.
 Sickle cell anemia is another illness
specific to African Americans.


Treatment Issues for African
Americans
Matriarchy; Mom or grandmother are the
dominant family figures.
 Lack of male role models and intact
families.
 Extended family or the Church may be
supports.


Treatment Issues for African
Americans


There is discrimination within their own
group based on skin color, hair texture,
class, values, etc.

Treatment Issues for Asians

Asians rarely seek help until its very severe.
Asians have extremely low admissions to state hospitals.
Mental illness is considered shameful. It’s hidden.
Is an interpreter needed?

Treatment Issues for Asians
Focus on physical symptoms.
 Asians are sensitive to medication.
 Give ½ the standard dose.
 Asians may use traditional healers and
herbal medicine.
 Asians may “flush” when drinking
alcohol.


Asian Consumers

Acupuncture has been used to treat
pain, schizophrenia, depression, and addictions.

Treatment Issues for Asians
Asian Cultures are patriarchal.
 The males in the family have the authority.
 Asians are more formal and inhibited in
their social behavior.


Older Adults

Treatment Issues for Older
Adults
Are they aware they need help?

Treatment Issues for Older
Adults
Is their mental illness caused by medicine?
 Do their medical problems cause or
complicate their mental illness?
 Is there Elder Abuse?


Gay Men and Lesbian Women
May struggle with homophobia and“being in the
closet” at work and with their families.
Gay people may want marriage, children, partner
benefits, etc., but may endure legal barriers.

Gay and Lesbian Women
Gay people often have specific health
issues related to their sexual practices.
 HIV, AIDS and STD’s are still concerns
with Gay men.
 People may be grieving the death of a
partner or friends who’ve died from AIDS,
or coping with living with AIDS or being
HIV+ themselves.


Treatment Issues for Gay and
Lesbians
Explore childhood abuse issues and
Domestic Violence..
 Assess for substance use and alcoholism.
 Sex enhancing drug use may be common
among some gay men.


Physically Challenged
Can they get to treatment?
Deal with their frustration and depression
Re: their disability.
 Do they need vocational assistance?

Mentally Challenged

Treatment Issues of Mentally
Challenged
They need to have meaningful activity
and purpose in their lives.
 They need to feel acknowledged and
appreciated.
 They need safety, structure, and security.
 Lack of continuity can cause crisis!
 They may need vocational assistance.


Winona Ryder

December 12, 2001,
Winona Ryder shoplifted
$5,560.40 designer items
from Saks Fifth Avenue in
Beverley Hills.

Twice an Academy
Award Nominated
actress

She had the following 8 drugs in
her possession:
Liquid demerol
 Liquid Diazepam
 Vicodin
 Percodan
 Valium
 Morphine sulfate
 Endocet (containing Oxycodone)


Patterns of Drug Use are highly
Regional.
 Drugs,

routes of administration, street
names, patterns of use, and drug
combinations may differ greatly, not
only between individuals from
different cultures, but different parts
of the country or even different parts
of the city.

Drugs of Choice
Native Americans-alcohol
 Asians-gambling, work
 Gay Men-stimulants, amyl nitrate, ecstasy
 “Rich”-prescription drugs, Internet porn
 M.D.’s –Vicodin


Drugs of Choice
Young adults-marijuana, cigarettes
 Geriatrics-alcohol, pills
 Sex Workers-crack cocaine, IV speedballs
 Screen mentally retarded for abuse too!


How Do We Best Serve Our
Consumers?




Examine own stereotypes.
Build trust.
Use People First language!

How do we best serve our
consumers?
Pronounce the person’s name correctly.
 Get an interpreter, if necessary.
 Educate yourself from the consumer, his
family, co-workers, etc.
 Remember differences do matter!



Slide 11

Cultural Competence
Integrating Differences
into Community Services

Objectives
Understand Stigma.
 Understand Culture Competency.
 Learn Culturally competent care for
people with Mental Health, Mental
Retardation and Addictions.


We live in an world
which often separates us.
Racism
 Sexism
 Ageism
 Feminism
 Classism
 Atheism


“Different” people are
“Stigmatized”

Mentally retarded inmates in a sanitorium in Germany

Stigma
Definitions from the U. of Chicago PSR Training Manual

“Stigmas are negative attitudes about a
group that lead to depriving them of
some fair opportunities.”

Stigma is related to…..
Stereotypes
Prejudice
Discrimination

Stereotypes
from The Asian Health Coalition of Illinois

Stereotypes are exaggerated beliefs
or fixed ideas about a person or
group which is held by people and
sustained by selective perception and
selective forgetting.

Prejudice
from The Asian Health Coalition of Illinois

Prejudice is a preconceived idea or
negative attitude formed before the
facts are known and sustained over
generalizations. A bias without
reason, resisting all evidence…

Discrimination
from The Asian Health Coalition of Illinois

Discrimination refers to treatment in
favor or against a person based on
the group to which that person
belongs and not on merit.

Stigmatized People…..
Experience being stereotyped and
are often the object of
discrimination and prejudice.

People are often stigmatized by:













Mental Illness
Mental Retardation
Physical Disability (including blindness, deafness)
Alcoholism /and or Drug Addiction
HIV or AIDS, Cancer or other terminal illnesses
Criminal behavior
Poverty
Alternative Lifestyles/sexual orientation
Wheelchair bound
Gender
Obesity

All our Consumers belong to
stigmatized groups!

Stigmatized People
Consumers and their families
can’t navigate the bureaucracy
even if resources are there.
It’s too frustrating!

Use People First Language
“I am more than my
illness….Don’t call me
“the schizophrenic,
“the addict” or
“the retard.”

As human beings, we have many
similarities…..
But, who we really are, is often
derived from our original family of origin
and our current lifestyle.

The Bottom Line:
People are different, even within
their own culture!
These differences matter when
planning and providing services.

National Mental Health
Association
“For Mental Health consumers, both
access to the services and the effectiveness
of the care they receive are greatly affected
by the degree to which the delivery system
is“culturally competent.”

Some important definitions
Related to Cultural Competency

Culture

from King,et. al

The Office of Special Programs, U.S. Dept. of Education

“The integrated patterns of human
behavior that includes thoughts,
communications, actions, customs,
beliefs,values, and institutions of
racial, ethnic, religious, or social
groups.”

Cultural Sensitivity
An awareness and respect of a
person’s cultural beliefs and
values.
Culhane-Pera, et .al

Cultural Competency
 Skills

(that translate into)
 Behaviors, Practices, Attitudes, and
 Policies
That enable an individual, agency, or
system to effectively serve culturally
diverse communities.
from The Asian Health Coalition of Illinois

Here at Hill Country MHDDC
Consumers are very diverse in their
language and culture.

61% of our Consumers are
Caucasian Americans
Many have German
backgrounds.

Our Consumers are …..

n
1% NativeAmerican

33% Hispanic
1% Asian

3% African
American

1% are “Others”

Consumers Have Many
Different Lifestyles

Lifestyles

They have many different
beliefs.

Can We Communicate?
Think Language first!
 Do we need an interpreter?
 Communicate respectfully.
 Be sensitive to the consumer and the family.
 Consider your dress, tone of voice, eye contact,
location, seating arrangement, privacy, etc.


Is our approach culturally
appropriate?
“What do you call your problem?”
“What name does it have?”
“What do you think caused your problem?”
“Why do you think it started when it did?”
From Arthur Kleinman’s question protocol in“Culture,Illness, and Care:
Clinical Lessons from Anthropologic and Cross Cultural Research”,
Ann.Intern.Med. 1978:Vol.88, pg.251-258

Important Issues to Consider…





Impact of religion.
How are women, men, elders, and children
treated in their culture?
Is there domestic violence?
Ethnic minorities generally underutilize
outpatient services, although African-Americans
are over-represented in inpatient setting.

Diagnosis






Minorities with Bipolar Disorder are often
diagnosed with schizophrenia. (Mukherjee,et al)
African Americans are over diagnosed with
schizophrenia and under diagnosed with mood
disorders. (Bell )
A mental health consumer’s addictions may not
be treated.
The elderly may not be assessed for substance
abuse or alcoholism.

Diagnosis
A person with a primary addiction problem
might not be treated for a co-occurring mental
illness.
 Learning disabilities may not be identified in
individuals with mental illness or substance
abuse.
 A person with mental retardation may not be
treated for mental illness or substance abuse.


Diagnosis
Post Traumatic Stress Disorder is often
undiagnosed in people suffering from
Domestic Abuse or other trauma.
 Children who are witnessing or are
victims of domestic abuse or another
trauma, may be misdiagnosed with
Attention Deficit Hyperactivity Disorder.


Medication Differences





Asians and Hispanics need lower doses of antipsychotics.
African Americans use the same doses of antipsychotics, but lower doses of lithium.
The elderly need lower dosages of medications.
Thus, metabolism of drugs varies with age and
ethnicity and is critical in prescribing
medications.

From “Making Room for Culture in Psychiatry” by Lin, et al.

Pain Tolerance
Men and women tolerate pain differently.
 Cultures tolerate pain differently.
 People with addictions develop a
hypersensitivity to pain.
 In certain cultures, self-inflicted pain is a
part of a religious experience.


Religion





Religious beliefs shape how the world is viewed.
Is illness a punishment? The devil’s work? An
evil spell? Bad karma?
For Hispanics, the curandero is a trusted healer.
For Lakota Sioux, the ritual Vision Quest,
praying and fasting at a holy site is life
changing.

Remember there are as many
differences
Between individuals in the same
culture as there are between
individuals in different cultures!

Two African American
families, one lesbian
and the other, multi-racial.

German Consumers
Suggestions from our Gillespie County MH staff

What generation German?
 Would they feel more comfortable
speaking in German?


A consumer reacting to internal stimuli.

German Consumers
Suggestions from our Gillespie MHC staff in Fredericksburg

They may be resistant to seeking
mental services.
They may be reluctant to take medication.
They may “keep things within the family.”
They are concerned about the stigma.

German Consumers
They may feel it’s a character flaw or a
disgrace.
 They are very concerned about
confidentiality.
 Drinking alcohol is an accepted part of
their culture.
 Teen drinking may be acceptable in their
family.


Hispanic Consumers
from the U.S. Census, 1/23/03 Houston Chronicle

Hispanics are the largest minority group in
the U.S. with 37 million people.
 Texas is approximately 32 percent
Hispanic
 11.5 % African American,
 3.3% Other
 53.1% Anglo


Treatment Issues for Hispanic
Consumers
Do we need an interpreter?
 Is the person Tejano or from Mexico?
What generation Hispanic?
Is the person using a curandero?

Treatment issues for Hispanic
Consumers
Hallucinations are natural in their
religion.
 Hearing the voice of a loved one or having
hallucinations might be an expectations
when celebrating the Day of the Dead.
 Hispanic families are patriarchal.


Hispanic Consumers and
The Day of the Dead
A man is dressed in a skeleton
costume to portray death
in a celebration of
Dia de los Muertos,
The Day of the Dead.
People visit the graves of their
dead relatives to honor them.

Native Americans

Treatment Issues for Native
American Consumers
 Impact of racism,unemployment,and poverty.
 Coping with reservation life and
assimilation in mainstream culture.
 Consider the obesity, diabetes,
hypertension, and alcoholism in adults
and fetal alcohol syndrome in children.
 High use of native healers in the Southwest.

African Americans

African Americans
from the Houston Chronicle, 1/23/03

There are 36.2 million Americans who
identify themselves as “black only.”
 37.7 million identify themselves as “black
and at least one other race.”
 11.5% of Texans are African Americans.


Treatment Issues for African
American
Assess for co-occurring substance use
disorders and alcoholism.
 Address complications of obesity,
hypertension, diabetes,congestive heart
failure, asthma, and cancer.
 Sickle cell anemia is another illness
specific to African Americans.


Treatment Issues for African
Americans
Matriarchy; Mom or grandmother are the
dominant family figures.
 Lack of male role models and intact
families.
 Extended family or the Church may be
supports.


Treatment Issues for African
Americans


There is discrimination within their own
group based on skin color, hair texture,
class, values, etc.

Treatment Issues for Asians

Asians rarely seek help until its very severe.
Asians have extremely low admissions to state hospitals.
Mental illness is considered shameful. It’s hidden.
Is an interpreter needed?

Treatment Issues for Asians
Focus on physical symptoms.
 Asians are sensitive to medication.
 Give ½ the standard dose.
 Asians may use traditional healers and
herbal medicine.
 Asians may “flush” when drinking
alcohol.


Asian Consumers

Acupuncture has been used to treat
pain, schizophrenia, depression, and addictions.

Treatment Issues for Asians
Asian Cultures are patriarchal.
 The males in the family have the authority.
 Asians are more formal and inhibited in
their social behavior.


Older Adults

Treatment Issues for Older
Adults
Are they aware they need help?

Treatment Issues for Older
Adults
Is their mental illness caused by medicine?
 Do their medical problems cause or
complicate their mental illness?
 Is there Elder Abuse?


Gay Men and Lesbian Women
May struggle with homophobia and“being in the
closet” at work and with their families.
Gay people may want marriage, children, partner
benefits, etc., but may endure legal barriers.

Gay and Lesbian Women
Gay people often have specific health
issues related to their sexual practices.
 HIV, AIDS and STD’s are still concerns
with Gay men.
 People may be grieving the death of a
partner or friends who’ve died from AIDS,
or coping with living with AIDS or being
HIV+ themselves.


Treatment Issues for Gay and
Lesbians
Explore childhood abuse issues and
Domestic Violence..
 Assess for substance use and alcoholism.
 Sex enhancing drug use may be common
among some gay men.


Physically Challenged
Can they get to treatment?
Deal with their frustration and depression
Re: their disability.
 Do they need vocational assistance?

Mentally Challenged

Treatment Issues of Mentally
Challenged
They need to have meaningful activity
and purpose in their lives.
 They need to feel acknowledged and
appreciated.
 They need safety, structure, and security.
 Lack of continuity can cause crisis!
 They may need vocational assistance.


Winona Ryder

December 12, 2001,
Winona Ryder shoplifted
$5,560.40 designer items
from Saks Fifth Avenue in
Beverley Hills.

Twice an Academy
Award Nominated
actress

She had the following 8 drugs in
her possession:
Liquid demerol
 Liquid Diazepam
 Vicodin
 Percodan
 Valium
 Morphine sulfate
 Endocet (containing Oxycodone)


Patterns of Drug Use are highly
Regional.
 Drugs,

routes of administration, street
names, patterns of use, and drug
combinations may differ greatly, not
only between individuals from
different cultures, but different parts
of the country or even different parts
of the city.

Drugs of Choice
Native Americans-alcohol
 Asians-gambling, work
 Gay Men-stimulants, amyl nitrate, ecstasy
 “Rich”-prescription drugs, Internet porn
 M.D.’s –Vicodin


Drugs of Choice
Young adults-marijuana, cigarettes
 Geriatrics-alcohol, pills
 Sex Workers-crack cocaine, IV speedballs
 Screen mentally retarded for abuse too!


How Do We Best Serve Our
Consumers?




Examine own stereotypes.
Build trust.
Use People First language!

How do we best serve our
consumers?
Pronounce the person’s name correctly.
 Get an interpreter, if necessary.
 Educate yourself from the consumer, his
family, co-workers, etc.
 Remember differences do matter!



Slide 12

Cultural Competence
Integrating Differences
into Community Services

Objectives
Understand Stigma.
 Understand Culture Competency.
 Learn Culturally competent care for
people with Mental Health, Mental
Retardation and Addictions.


We live in an world
which often separates us.
Racism
 Sexism
 Ageism
 Feminism
 Classism
 Atheism


“Different” people are
“Stigmatized”

Mentally retarded inmates in a sanitorium in Germany

Stigma
Definitions from the U. of Chicago PSR Training Manual

“Stigmas are negative attitudes about a
group that lead to depriving them of
some fair opportunities.”

Stigma is related to…..
Stereotypes
Prejudice
Discrimination

Stereotypes
from The Asian Health Coalition of Illinois

Stereotypes are exaggerated beliefs
or fixed ideas about a person or
group which is held by people and
sustained by selective perception and
selective forgetting.

Prejudice
from The Asian Health Coalition of Illinois

Prejudice is a preconceived idea or
negative attitude formed before the
facts are known and sustained over
generalizations. A bias without
reason, resisting all evidence…

Discrimination
from The Asian Health Coalition of Illinois

Discrimination refers to treatment in
favor or against a person based on
the group to which that person
belongs and not on merit.

Stigmatized People…..
Experience being stereotyped and
are often the object of
discrimination and prejudice.

People are often stigmatized by:













Mental Illness
Mental Retardation
Physical Disability (including blindness, deafness)
Alcoholism /and or Drug Addiction
HIV or AIDS, Cancer or other terminal illnesses
Criminal behavior
Poverty
Alternative Lifestyles/sexual orientation
Wheelchair bound
Gender
Obesity

All our Consumers belong to
stigmatized groups!

Stigmatized People
Consumers and their families
can’t navigate the bureaucracy
even if resources are there.
It’s too frustrating!

Use People First Language
“I am more than my
illness….Don’t call me
“the schizophrenic,
“the addict” or
“the retard.”

As human beings, we have many
similarities…..
But, who we really are, is often
derived from our original family of origin
and our current lifestyle.

The Bottom Line:
People are different, even within
their own culture!
These differences matter when
planning and providing services.

National Mental Health
Association
“For Mental Health consumers, both
access to the services and the effectiveness
of the care they receive are greatly affected
by the degree to which the delivery system
is“culturally competent.”

Some important definitions
Related to Cultural Competency

Culture

from King,et. al

The Office of Special Programs, U.S. Dept. of Education

“The integrated patterns of human
behavior that includes thoughts,
communications, actions, customs,
beliefs,values, and institutions of
racial, ethnic, religious, or social
groups.”

Cultural Sensitivity
An awareness and respect of a
person’s cultural beliefs and
values.
Culhane-Pera, et .al

Cultural Competency
 Skills

(that translate into)
 Behaviors, Practices, Attitudes, and
 Policies
That enable an individual, agency, or
system to effectively serve culturally
diverse communities.
from The Asian Health Coalition of Illinois

Here at Hill Country MHDDC
Consumers are very diverse in their
language and culture.

61% of our Consumers are
Caucasian Americans
Many have German
backgrounds.

Our Consumers are …..

n
1% NativeAmerican

33% Hispanic
1% Asian

3% African
American

1% are “Others”

Consumers Have Many
Different Lifestyles

Lifestyles

They have many different
beliefs.

Can We Communicate?
Think Language first!
 Do we need an interpreter?
 Communicate respectfully.
 Be sensitive to the consumer and the family.
 Consider your dress, tone of voice, eye contact,
location, seating arrangement, privacy, etc.


Is our approach culturally
appropriate?
“What do you call your problem?”
“What name does it have?”
“What do you think caused your problem?”
“Why do you think it started when it did?”
From Arthur Kleinman’s question protocol in“Culture,Illness, and Care:
Clinical Lessons from Anthropologic and Cross Cultural Research”,
Ann.Intern.Med. 1978:Vol.88, pg.251-258

Important Issues to Consider…





Impact of religion.
How are women, men, elders, and children
treated in their culture?
Is there domestic violence?
Ethnic minorities generally underutilize
outpatient services, although African-Americans
are over-represented in inpatient setting.

Diagnosis






Minorities with Bipolar Disorder are often
diagnosed with schizophrenia. (Mukherjee,et al)
African Americans are over diagnosed with
schizophrenia and under diagnosed with mood
disorders. (Bell )
A mental health consumer’s addictions may not
be treated.
The elderly may not be assessed for substance
abuse or alcoholism.

Diagnosis
A person with a primary addiction problem
might not be treated for a co-occurring mental
illness.
 Learning disabilities may not be identified in
individuals with mental illness or substance
abuse.
 A person with mental retardation may not be
treated for mental illness or substance abuse.


Diagnosis
Post Traumatic Stress Disorder is often
undiagnosed in people suffering from
Domestic Abuse or other trauma.
 Children who are witnessing or are
victims of domestic abuse or another
trauma, may be misdiagnosed with
Attention Deficit Hyperactivity Disorder.


Medication Differences





Asians and Hispanics need lower doses of antipsychotics.
African Americans use the same doses of antipsychotics, but lower doses of lithium.
The elderly need lower dosages of medications.
Thus, metabolism of drugs varies with age and
ethnicity and is critical in prescribing
medications.

From “Making Room for Culture in Psychiatry” by Lin, et al.

Pain Tolerance
Men and women tolerate pain differently.
 Cultures tolerate pain differently.
 People with addictions develop a
hypersensitivity to pain.
 In certain cultures, self-inflicted pain is a
part of a religious experience.


Religion





Religious beliefs shape how the world is viewed.
Is illness a punishment? The devil’s work? An
evil spell? Bad karma?
For Hispanics, the curandero is a trusted healer.
For Lakota Sioux, the ritual Vision Quest,
praying and fasting at a holy site is life
changing.

Remember there are as many
differences
Between individuals in the same
culture as there are between
individuals in different cultures!

Two African American
families, one lesbian
and the other, multi-racial.

German Consumers
Suggestions from our Gillespie County MH staff

What generation German?
 Would they feel more comfortable
speaking in German?


A consumer reacting to internal stimuli.

German Consumers
Suggestions from our Gillespie MHC staff in Fredericksburg

They may be resistant to seeking
mental services.
They may be reluctant to take medication.
They may “keep things within the family.”
They are concerned about the stigma.

German Consumers
They may feel it’s a character flaw or a
disgrace.
 They are very concerned about
confidentiality.
 Drinking alcohol is an accepted part of
their culture.
 Teen drinking may be acceptable in their
family.


Hispanic Consumers
from the U.S. Census, 1/23/03 Houston Chronicle

Hispanics are the largest minority group in
the U.S. with 37 million people.
 Texas is approximately 32 percent
Hispanic
 11.5 % African American,
 3.3% Other
 53.1% Anglo


Treatment Issues for Hispanic
Consumers
Do we need an interpreter?
 Is the person Tejano or from Mexico?
What generation Hispanic?
Is the person using a curandero?

Treatment issues for Hispanic
Consumers
Hallucinations are natural in their
religion.
 Hearing the voice of a loved one or having
hallucinations might be an expectations
when celebrating the Day of the Dead.
 Hispanic families are patriarchal.


Hispanic Consumers and
The Day of the Dead
A man is dressed in a skeleton
costume to portray death
in a celebration of
Dia de los Muertos,
The Day of the Dead.
People visit the graves of their
dead relatives to honor them.

Native Americans

Treatment Issues for Native
American Consumers
 Impact of racism,unemployment,and poverty.
 Coping with reservation life and
assimilation in mainstream culture.
 Consider the obesity, diabetes,
hypertension, and alcoholism in adults
and fetal alcohol syndrome in children.
 High use of native healers in the Southwest.

African Americans

African Americans
from the Houston Chronicle, 1/23/03

There are 36.2 million Americans who
identify themselves as “black only.”
 37.7 million identify themselves as “black
and at least one other race.”
 11.5% of Texans are African Americans.


Treatment Issues for African
American
Assess for co-occurring substance use
disorders and alcoholism.
 Address complications of obesity,
hypertension, diabetes,congestive heart
failure, asthma, and cancer.
 Sickle cell anemia is another illness
specific to African Americans.


Treatment Issues for African
Americans
Matriarchy; Mom or grandmother are the
dominant family figures.
 Lack of male role models and intact
families.
 Extended family or the Church may be
supports.


Treatment Issues for African
Americans


There is discrimination within their own
group based on skin color, hair texture,
class, values, etc.

Treatment Issues for Asians

Asians rarely seek help until its very severe.
Asians have extremely low admissions to state hospitals.
Mental illness is considered shameful. It’s hidden.
Is an interpreter needed?

Treatment Issues for Asians
Focus on physical symptoms.
 Asians are sensitive to medication.
 Give ½ the standard dose.
 Asians may use traditional healers and
herbal medicine.
 Asians may “flush” when drinking
alcohol.


Asian Consumers

Acupuncture has been used to treat
pain, schizophrenia, depression, and addictions.

Treatment Issues for Asians
Asian Cultures are patriarchal.
 The males in the family have the authority.
 Asians are more formal and inhibited in
their social behavior.


Older Adults

Treatment Issues for Older
Adults
Are they aware they need help?

Treatment Issues for Older
Adults
Is their mental illness caused by medicine?
 Do their medical problems cause or
complicate their mental illness?
 Is there Elder Abuse?


Gay Men and Lesbian Women
May struggle with homophobia and“being in the
closet” at work and with their families.
Gay people may want marriage, children, partner
benefits, etc., but may endure legal barriers.

Gay and Lesbian Women
Gay people often have specific health
issues related to their sexual practices.
 HIV, AIDS and STD’s are still concerns
with Gay men.
 People may be grieving the death of a
partner or friends who’ve died from AIDS,
or coping with living with AIDS or being
HIV+ themselves.


Treatment Issues for Gay and
Lesbians
Explore childhood abuse issues and
Domestic Violence..
 Assess for substance use and alcoholism.
 Sex enhancing drug use may be common
among some gay men.


Physically Challenged
Can they get to treatment?
Deal with their frustration and depression
Re: their disability.
 Do they need vocational assistance?

Mentally Challenged

Treatment Issues of Mentally
Challenged
They need to have meaningful activity
and purpose in their lives.
 They need to feel acknowledged and
appreciated.
 They need safety, structure, and security.
 Lack of continuity can cause crisis!
 They may need vocational assistance.


Winona Ryder

December 12, 2001,
Winona Ryder shoplifted
$5,560.40 designer items
from Saks Fifth Avenue in
Beverley Hills.

Twice an Academy
Award Nominated
actress

She had the following 8 drugs in
her possession:
Liquid demerol
 Liquid Diazepam
 Vicodin
 Percodan
 Valium
 Morphine sulfate
 Endocet (containing Oxycodone)


Patterns of Drug Use are highly
Regional.
 Drugs,

routes of administration, street
names, patterns of use, and drug
combinations may differ greatly, not
only between individuals from
different cultures, but different parts
of the country or even different parts
of the city.

Drugs of Choice
Native Americans-alcohol
 Asians-gambling, work
 Gay Men-stimulants, amyl nitrate, ecstasy
 “Rich”-prescription drugs, Internet porn
 M.D.’s –Vicodin


Drugs of Choice
Young adults-marijuana, cigarettes
 Geriatrics-alcohol, pills
 Sex Workers-crack cocaine, IV speedballs
 Screen mentally retarded for abuse too!


How Do We Best Serve Our
Consumers?




Examine own stereotypes.
Build trust.
Use People First language!

How do we best serve our
consumers?
Pronounce the person’s name correctly.
 Get an interpreter, if necessary.
 Educate yourself from the consumer, his
family, co-workers, etc.
 Remember differences do matter!



Slide 13

Cultural Competence
Integrating Differences
into Community Services

Objectives
Understand Stigma.
 Understand Culture Competency.
 Learn Culturally competent care for
people with Mental Health, Mental
Retardation and Addictions.


We live in an world
which often separates us.
Racism
 Sexism
 Ageism
 Feminism
 Classism
 Atheism


“Different” people are
“Stigmatized”

Mentally retarded inmates in a sanitorium in Germany

Stigma
Definitions from the U. of Chicago PSR Training Manual

“Stigmas are negative attitudes about a
group that lead to depriving them of
some fair opportunities.”

Stigma is related to…..
Stereotypes
Prejudice
Discrimination

Stereotypes
from The Asian Health Coalition of Illinois

Stereotypes are exaggerated beliefs
or fixed ideas about a person or
group which is held by people and
sustained by selective perception and
selective forgetting.

Prejudice
from The Asian Health Coalition of Illinois

Prejudice is a preconceived idea or
negative attitude formed before the
facts are known and sustained over
generalizations. A bias without
reason, resisting all evidence…

Discrimination
from The Asian Health Coalition of Illinois

Discrimination refers to treatment in
favor or against a person based on
the group to which that person
belongs and not on merit.

Stigmatized People…..
Experience being stereotyped and
are often the object of
discrimination and prejudice.

People are often stigmatized by:













Mental Illness
Mental Retardation
Physical Disability (including blindness, deafness)
Alcoholism /and or Drug Addiction
HIV or AIDS, Cancer or other terminal illnesses
Criminal behavior
Poverty
Alternative Lifestyles/sexual orientation
Wheelchair bound
Gender
Obesity

All our Consumers belong to
stigmatized groups!

Stigmatized People
Consumers and their families
can’t navigate the bureaucracy
even if resources are there.
It’s too frustrating!

Use People First Language
“I am more than my
illness….Don’t call me
“the schizophrenic,
“the addict” or
“the retard.”

As human beings, we have many
similarities…..
But, who we really are, is often
derived from our original family of origin
and our current lifestyle.

The Bottom Line:
People are different, even within
their own culture!
These differences matter when
planning and providing services.

National Mental Health
Association
“For Mental Health consumers, both
access to the services and the effectiveness
of the care they receive are greatly affected
by the degree to which the delivery system
is“culturally competent.”

Some important definitions
Related to Cultural Competency

Culture

from King,et. al

The Office of Special Programs, U.S. Dept. of Education

“The integrated patterns of human
behavior that includes thoughts,
communications, actions, customs,
beliefs,values, and institutions of
racial, ethnic, religious, or social
groups.”

Cultural Sensitivity
An awareness and respect of a
person’s cultural beliefs and
values.
Culhane-Pera, et .al

Cultural Competency
 Skills

(that translate into)
 Behaviors, Practices, Attitudes, and
 Policies
That enable an individual, agency, or
system to effectively serve culturally
diverse communities.
from The Asian Health Coalition of Illinois

Here at Hill Country MHDDC
Consumers are very diverse in their
language and culture.

61% of our Consumers are
Caucasian Americans
Many have German
backgrounds.

Our Consumers are …..

n
1% NativeAmerican

33% Hispanic
1% Asian

3% African
American

1% are “Others”

Consumers Have Many
Different Lifestyles

Lifestyles

They have many different
beliefs.

Can We Communicate?
Think Language first!
 Do we need an interpreter?
 Communicate respectfully.
 Be sensitive to the consumer and the family.
 Consider your dress, tone of voice, eye contact,
location, seating arrangement, privacy, etc.


Is our approach culturally
appropriate?
“What do you call your problem?”
“What name does it have?”
“What do you think caused your problem?”
“Why do you think it started when it did?”
From Arthur Kleinman’s question protocol in“Culture,Illness, and Care:
Clinical Lessons from Anthropologic and Cross Cultural Research”,
Ann.Intern.Med. 1978:Vol.88, pg.251-258

Important Issues to Consider…





Impact of religion.
How are women, men, elders, and children
treated in their culture?
Is there domestic violence?
Ethnic minorities generally underutilize
outpatient services, although African-Americans
are over-represented in inpatient setting.

Diagnosis






Minorities with Bipolar Disorder are often
diagnosed with schizophrenia. (Mukherjee,et al)
African Americans are over diagnosed with
schizophrenia and under diagnosed with mood
disorders. (Bell )
A mental health consumer’s addictions may not
be treated.
The elderly may not be assessed for substance
abuse or alcoholism.

Diagnosis
A person with a primary addiction problem
might not be treated for a co-occurring mental
illness.
 Learning disabilities may not be identified in
individuals with mental illness or substance
abuse.
 A person with mental retardation may not be
treated for mental illness or substance abuse.


Diagnosis
Post Traumatic Stress Disorder is often
undiagnosed in people suffering from
Domestic Abuse or other trauma.
 Children who are witnessing or are
victims of domestic abuse or another
trauma, may be misdiagnosed with
Attention Deficit Hyperactivity Disorder.


Medication Differences





Asians and Hispanics need lower doses of antipsychotics.
African Americans use the same doses of antipsychotics, but lower doses of lithium.
The elderly need lower dosages of medications.
Thus, metabolism of drugs varies with age and
ethnicity and is critical in prescribing
medications.

From “Making Room for Culture in Psychiatry” by Lin, et al.

Pain Tolerance
Men and women tolerate pain differently.
 Cultures tolerate pain differently.
 People with addictions develop a
hypersensitivity to pain.
 In certain cultures, self-inflicted pain is a
part of a religious experience.


Religion





Religious beliefs shape how the world is viewed.
Is illness a punishment? The devil’s work? An
evil spell? Bad karma?
For Hispanics, the curandero is a trusted healer.
For Lakota Sioux, the ritual Vision Quest,
praying and fasting at a holy site is life
changing.

Remember there are as many
differences
Between individuals in the same
culture as there are between
individuals in different cultures!

Two African American
families, one lesbian
and the other, multi-racial.

German Consumers
Suggestions from our Gillespie County MH staff

What generation German?
 Would they feel more comfortable
speaking in German?


A consumer reacting to internal stimuli.

German Consumers
Suggestions from our Gillespie MHC staff in Fredericksburg

They may be resistant to seeking
mental services.
They may be reluctant to take medication.
They may “keep things within the family.”
They are concerned about the stigma.

German Consumers
They may feel it’s a character flaw or a
disgrace.
 They are very concerned about
confidentiality.
 Drinking alcohol is an accepted part of
their culture.
 Teen drinking may be acceptable in their
family.


Hispanic Consumers
from the U.S. Census, 1/23/03 Houston Chronicle

Hispanics are the largest minority group in
the U.S. with 37 million people.
 Texas is approximately 32 percent
Hispanic
 11.5 % African American,
 3.3% Other
 53.1% Anglo


Treatment Issues for Hispanic
Consumers
Do we need an interpreter?
 Is the person Tejano or from Mexico?
What generation Hispanic?
Is the person using a curandero?

Treatment issues for Hispanic
Consumers
Hallucinations are natural in their
religion.
 Hearing the voice of a loved one or having
hallucinations might be an expectations
when celebrating the Day of the Dead.
 Hispanic families are patriarchal.


Hispanic Consumers and
The Day of the Dead
A man is dressed in a skeleton
costume to portray death
in a celebration of
Dia de los Muertos,
The Day of the Dead.
People visit the graves of their
dead relatives to honor them.

Native Americans

Treatment Issues for Native
American Consumers
 Impact of racism,unemployment,and poverty.
 Coping with reservation life and
assimilation in mainstream culture.
 Consider the obesity, diabetes,
hypertension, and alcoholism in adults
and fetal alcohol syndrome in children.
 High use of native healers in the Southwest.

African Americans

African Americans
from the Houston Chronicle, 1/23/03

There are 36.2 million Americans who
identify themselves as “black only.”
 37.7 million identify themselves as “black
and at least one other race.”
 11.5% of Texans are African Americans.


Treatment Issues for African
American
Assess for co-occurring substance use
disorders and alcoholism.
 Address complications of obesity,
hypertension, diabetes,congestive heart
failure, asthma, and cancer.
 Sickle cell anemia is another illness
specific to African Americans.


Treatment Issues for African
Americans
Matriarchy; Mom or grandmother are the
dominant family figures.
 Lack of male role models and intact
families.
 Extended family or the Church may be
supports.


Treatment Issues for African
Americans


There is discrimination within their own
group based on skin color, hair texture,
class, values, etc.

Treatment Issues for Asians

Asians rarely seek help until its very severe.
Asians have extremely low admissions to state hospitals.
Mental illness is considered shameful. It’s hidden.
Is an interpreter needed?

Treatment Issues for Asians
Focus on physical symptoms.
 Asians are sensitive to medication.
 Give ½ the standard dose.
 Asians may use traditional healers and
herbal medicine.
 Asians may “flush” when drinking
alcohol.


Asian Consumers

Acupuncture has been used to treat
pain, schizophrenia, depression, and addictions.

Treatment Issues for Asians
Asian Cultures are patriarchal.
 The males in the family have the authority.
 Asians are more formal and inhibited in
their social behavior.


Older Adults

Treatment Issues for Older
Adults
Are they aware they need help?

Treatment Issues for Older
Adults
Is their mental illness caused by medicine?
 Do their medical problems cause or
complicate their mental illness?
 Is there Elder Abuse?


Gay Men and Lesbian Women
May struggle with homophobia and“being in the
closet” at work and with their families.
Gay people may want marriage, children, partner
benefits, etc., but may endure legal barriers.

Gay and Lesbian Women
Gay people often have specific health
issues related to their sexual practices.
 HIV, AIDS and STD’s are still concerns
with Gay men.
 People may be grieving the death of a
partner or friends who’ve died from AIDS,
or coping with living with AIDS or being
HIV+ themselves.


Treatment Issues for Gay and
Lesbians
Explore childhood abuse issues and
Domestic Violence..
 Assess for substance use and alcoholism.
 Sex enhancing drug use may be common
among some gay men.


Physically Challenged
Can they get to treatment?
Deal with their frustration and depression
Re: their disability.
 Do they need vocational assistance?

Mentally Challenged

Treatment Issues of Mentally
Challenged
They need to have meaningful activity
and purpose in their lives.
 They need to feel acknowledged and
appreciated.
 They need safety, structure, and security.
 Lack of continuity can cause crisis!
 They may need vocational assistance.


Winona Ryder

December 12, 2001,
Winona Ryder shoplifted
$5,560.40 designer items
from Saks Fifth Avenue in
Beverley Hills.

Twice an Academy
Award Nominated
actress

She had the following 8 drugs in
her possession:
Liquid demerol
 Liquid Diazepam
 Vicodin
 Percodan
 Valium
 Morphine sulfate
 Endocet (containing Oxycodone)


Patterns of Drug Use are highly
Regional.
 Drugs,

routes of administration, street
names, patterns of use, and drug
combinations may differ greatly, not
only between individuals from
different cultures, but different parts
of the country or even different parts
of the city.

Drugs of Choice
Native Americans-alcohol
 Asians-gambling, work
 Gay Men-stimulants, amyl nitrate, ecstasy
 “Rich”-prescription drugs, Internet porn
 M.D.’s –Vicodin


Drugs of Choice
Young adults-marijuana, cigarettes
 Geriatrics-alcohol, pills
 Sex Workers-crack cocaine, IV speedballs
 Screen mentally retarded for abuse too!


How Do We Best Serve Our
Consumers?




Examine own stereotypes.
Build trust.
Use People First language!

How do we best serve our
consumers?
Pronounce the person’s name correctly.
 Get an interpreter, if necessary.
 Educate yourself from the consumer, his
family, co-workers, etc.
 Remember differences do matter!



Slide 14

Cultural Competence
Integrating Differences
into Community Services

Objectives
Understand Stigma.
 Understand Culture Competency.
 Learn Culturally competent care for
people with Mental Health, Mental
Retardation and Addictions.


We live in an world
which often separates us.
Racism
 Sexism
 Ageism
 Feminism
 Classism
 Atheism


“Different” people are
“Stigmatized”

Mentally retarded inmates in a sanitorium in Germany

Stigma
Definitions from the U. of Chicago PSR Training Manual

“Stigmas are negative attitudes about a
group that lead to depriving them of
some fair opportunities.”

Stigma is related to…..
Stereotypes
Prejudice
Discrimination

Stereotypes
from The Asian Health Coalition of Illinois

Stereotypes are exaggerated beliefs
or fixed ideas about a person or
group which is held by people and
sustained by selective perception and
selective forgetting.

Prejudice
from The Asian Health Coalition of Illinois

Prejudice is a preconceived idea or
negative attitude formed before the
facts are known and sustained over
generalizations. A bias without
reason, resisting all evidence…

Discrimination
from The Asian Health Coalition of Illinois

Discrimination refers to treatment in
favor or against a person based on
the group to which that person
belongs and not on merit.

Stigmatized People…..
Experience being stereotyped and
are often the object of
discrimination and prejudice.

People are often stigmatized by:













Mental Illness
Mental Retardation
Physical Disability (including blindness, deafness)
Alcoholism /and or Drug Addiction
HIV or AIDS, Cancer or other terminal illnesses
Criminal behavior
Poverty
Alternative Lifestyles/sexual orientation
Wheelchair bound
Gender
Obesity

All our Consumers belong to
stigmatized groups!

Stigmatized People
Consumers and their families
can’t navigate the bureaucracy
even if resources are there.
It’s too frustrating!

Use People First Language
“I am more than my
illness….Don’t call me
“the schizophrenic,
“the addict” or
“the retard.”

As human beings, we have many
similarities…..
But, who we really are, is often
derived from our original family of origin
and our current lifestyle.

The Bottom Line:
People are different, even within
their own culture!
These differences matter when
planning and providing services.

National Mental Health
Association
“For Mental Health consumers, both
access to the services and the effectiveness
of the care they receive are greatly affected
by the degree to which the delivery system
is“culturally competent.”

Some important definitions
Related to Cultural Competency

Culture

from King,et. al

The Office of Special Programs, U.S. Dept. of Education

“The integrated patterns of human
behavior that includes thoughts,
communications, actions, customs,
beliefs,values, and institutions of
racial, ethnic, religious, or social
groups.”

Cultural Sensitivity
An awareness and respect of a
person’s cultural beliefs and
values.
Culhane-Pera, et .al

Cultural Competency
 Skills

(that translate into)
 Behaviors, Practices, Attitudes, and
 Policies
That enable an individual, agency, or
system to effectively serve culturally
diverse communities.
from The Asian Health Coalition of Illinois

Here at Hill Country MHDDC
Consumers are very diverse in their
language and culture.

61% of our Consumers are
Caucasian Americans
Many have German
backgrounds.

Our Consumers are …..

n
1% NativeAmerican

33% Hispanic
1% Asian

3% African
American

1% are “Others”

Consumers Have Many
Different Lifestyles

Lifestyles

They have many different
beliefs.

Can We Communicate?
Think Language first!
 Do we need an interpreter?
 Communicate respectfully.
 Be sensitive to the consumer and the family.
 Consider your dress, tone of voice, eye contact,
location, seating arrangement, privacy, etc.


Is our approach culturally
appropriate?
“What do you call your problem?”
“What name does it have?”
“What do you think caused your problem?”
“Why do you think it started when it did?”
From Arthur Kleinman’s question protocol in“Culture,Illness, and Care:
Clinical Lessons from Anthropologic and Cross Cultural Research”,
Ann.Intern.Med. 1978:Vol.88, pg.251-258

Important Issues to Consider…





Impact of religion.
How are women, men, elders, and children
treated in their culture?
Is there domestic violence?
Ethnic minorities generally underutilize
outpatient services, although African-Americans
are over-represented in inpatient setting.

Diagnosis






Minorities with Bipolar Disorder are often
diagnosed with schizophrenia. (Mukherjee,et al)
African Americans are over diagnosed with
schizophrenia and under diagnosed with mood
disorders. (Bell )
A mental health consumer’s addictions may not
be treated.
The elderly may not be assessed for substance
abuse or alcoholism.

Diagnosis
A person with a primary addiction problem
might not be treated for a co-occurring mental
illness.
 Learning disabilities may not be identified in
individuals with mental illness or substance
abuse.
 A person with mental retardation may not be
treated for mental illness or substance abuse.


Diagnosis
Post Traumatic Stress Disorder is often
undiagnosed in people suffering from
Domestic Abuse or other trauma.
 Children who are witnessing or are
victims of domestic abuse or another
trauma, may be misdiagnosed with
Attention Deficit Hyperactivity Disorder.


Medication Differences





Asians and Hispanics need lower doses of antipsychotics.
African Americans use the same doses of antipsychotics, but lower doses of lithium.
The elderly need lower dosages of medications.
Thus, metabolism of drugs varies with age and
ethnicity and is critical in prescribing
medications.

From “Making Room for Culture in Psychiatry” by Lin, et al.

Pain Tolerance
Men and women tolerate pain differently.
 Cultures tolerate pain differently.
 People with addictions develop a
hypersensitivity to pain.
 In certain cultures, self-inflicted pain is a
part of a religious experience.


Religion





Religious beliefs shape how the world is viewed.
Is illness a punishment? The devil’s work? An
evil spell? Bad karma?
For Hispanics, the curandero is a trusted healer.
For Lakota Sioux, the ritual Vision Quest,
praying and fasting at a holy site is life
changing.

Remember there are as many
differences
Between individuals in the same
culture as there are between
individuals in different cultures!

Two African American
families, one lesbian
and the other, multi-racial.

German Consumers
Suggestions from our Gillespie County MH staff

What generation German?
 Would they feel more comfortable
speaking in German?


A consumer reacting to internal stimuli.

German Consumers
Suggestions from our Gillespie MHC staff in Fredericksburg

They may be resistant to seeking
mental services.
They may be reluctant to take medication.
They may “keep things within the family.”
They are concerned about the stigma.

German Consumers
They may feel it’s a character flaw or a
disgrace.
 They are very concerned about
confidentiality.
 Drinking alcohol is an accepted part of
their culture.
 Teen drinking may be acceptable in their
family.


Hispanic Consumers
from the U.S. Census, 1/23/03 Houston Chronicle

Hispanics are the largest minority group in
the U.S. with 37 million people.
 Texas is approximately 32 percent
Hispanic
 11.5 % African American,
 3.3% Other
 53.1% Anglo


Treatment Issues for Hispanic
Consumers
Do we need an interpreter?
 Is the person Tejano or from Mexico?
What generation Hispanic?
Is the person using a curandero?

Treatment issues for Hispanic
Consumers
Hallucinations are natural in their
religion.
 Hearing the voice of a loved one or having
hallucinations might be an expectations
when celebrating the Day of the Dead.
 Hispanic families are patriarchal.


Hispanic Consumers and
The Day of the Dead
A man is dressed in a skeleton
costume to portray death
in a celebration of
Dia de los Muertos,
The Day of the Dead.
People visit the graves of their
dead relatives to honor them.

Native Americans

Treatment Issues for Native
American Consumers
 Impact of racism,unemployment,and poverty.
 Coping with reservation life and
assimilation in mainstream culture.
 Consider the obesity, diabetes,
hypertension, and alcoholism in adults
and fetal alcohol syndrome in children.
 High use of native healers in the Southwest.

African Americans

African Americans
from the Houston Chronicle, 1/23/03

There are 36.2 million Americans who
identify themselves as “black only.”
 37.7 million identify themselves as “black
and at least one other race.”
 11.5% of Texans are African Americans.


Treatment Issues for African
American
Assess for co-occurring substance use
disorders and alcoholism.
 Address complications of obesity,
hypertension, diabetes,congestive heart
failure, asthma, and cancer.
 Sickle cell anemia is another illness
specific to African Americans.


Treatment Issues for African
Americans
Matriarchy; Mom or grandmother are the
dominant family figures.
 Lack of male role models and intact
families.
 Extended family or the Church may be
supports.


Treatment Issues for African
Americans


There is discrimination within their own
group based on skin color, hair texture,
class, values, etc.

Treatment Issues for Asians

Asians rarely seek help until its very severe.
Asians have extremely low admissions to state hospitals.
Mental illness is considered shameful. It’s hidden.
Is an interpreter needed?

Treatment Issues for Asians
Focus on physical symptoms.
 Asians are sensitive to medication.
 Give ½ the standard dose.
 Asians may use traditional healers and
herbal medicine.
 Asians may “flush” when drinking
alcohol.


Asian Consumers

Acupuncture has been used to treat
pain, schizophrenia, depression, and addictions.

Treatment Issues for Asians
Asian Cultures are patriarchal.
 The males in the family have the authority.
 Asians are more formal and inhibited in
their social behavior.


Older Adults

Treatment Issues for Older
Adults
Are they aware they need help?

Treatment Issues for Older
Adults
Is their mental illness caused by medicine?
 Do their medical problems cause or
complicate their mental illness?
 Is there Elder Abuse?


Gay Men and Lesbian Women
May struggle with homophobia and“being in the
closet” at work and with their families.
Gay people may want marriage, children, partner
benefits, etc., but may endure legal barriers.

Gay and Lesbian Women
Gay people often have specific health
issues related to their sexual practices.
 HIV, AIDS and STD’s are still concerns
with Gay men.
 People may be grieving the death of a
partner or friends who’ve died from AIDS,
or coping with living with AIDS or being
HIV+ themselves.


Treatment Issues for Gay and
Lesbians
Explore childhood abuse issues and
Domestic Violence..
 Assess for substance use and alcoholism.
 Sex enhancing drug use may be common
among some gay men.


Physically Challenged
Can they get to treatment?
Deal with their frustration and depression
Re: their disability.
 Do they need vocational assistance?

Mentally Challenged

Treatment Issues of Mentally
Challenged
They need to have meaningful activity
and purpose in their lives.
 They need to feel acknowledged and
appreciated.
 They need safety, structure, and security.
 Lack of continuity can cause crisis!
 They may need vocational assistance.


Winona Ryder

December 12, 2001,
Winona Ryder shoplifted
$5,560.40 designer items
from Saks Fifth Avenue in
Beverley Hills.

Twice an Academy
Award Nominated
actress

She had the following 8 drugs in
her possession:
Liquid demerol
 Liquid Diazepam
 Vicodin
 Percodan
 Valium
 Morphine sulfate
 Endocet (containing Oxycodone)


Patterns of Drug Use are highly
Regional.
 Drugs,

routes of administration, street
names, patterns of use, and drug
combinations may differ greatly, not
only between individuals from
different cultures, but different parts
of the country or even different parts
of the city.

Drugs of Choice
Native Americans-alcohol
 Asians-gambling, work
 Gay Men-stimulants, amyl nitrate, ecstasy
 “Rich”-prescription drugs, Internet porn
 M.D.’s –Vicodin


Drugs of Choice
Young adults-marijuana, cigarettes
 Geriatrics-alcohol, pills
 Sex Workers-crack cocaine, IV speedballs
 Screen mentally retarded for abuse too!


How Do We Best Serve Our
Consumers?




Examine own stereotypes.
Build trust.
Use People First language!

How do we best serve our
consumers?
Pronounce the person’s name correctly.
 Get an interpreter, if necessary.
 Educate yourself from the consumer, his
family, co-workers, etc.
 Remember differences do matter!



Slide 15

Cultural Competence
Integrating Differences
into Community Services

Objectives
Understand Stigma.
 Understand Culture Competency.
 Learn Culturally competent care for
people with Mental Health, Mental
Retardation and Addictions.


We live in an world
which often separates us.
Racism
 Sexism
 Ageism
 Feminism
 Classism
 Atheism


“Different” people are
“Stigmatized”

Mentally retarded inmates in a sanitorium in Germany

Stigma
Definitions from the U. of Chicago PSR Training Manual

“Stigmas are negative attitudes about a
group that lead to depriving them of
some fair opportunities.”

Stigma is related to…..
Stereotypes
Prejudice
Discrimination

Stereotypes
from The Asian Health Coalition of Illinois

Stereotypes are exaggerated beliefs
or fixed ideas about a person or
group which is held by people and
sustained by selective perception and
selective forgetting.

Prejudice
from The Asian Health Coalition of Illinois

Prejudice is a preconceived idea or
negative attitude formed before the
facts are known and sustained over
generalizations. A bias without
reason, resisting all evidence…

Discrimination
from The Asian Health Coalition of Illinois

Discrimination refers to treatment in
favor or against a person based on
the group to which that person
belongs and not on merit.

Stigmatized People…..
Experience being stereotyped and
are often the object of
discrimination and prejudice.

People are often stigmatized by:













Mental Illness
Mental Retardation
Physical Disability (including blindness, deafness)
Alcoholism /and or Drug Addiction
HIV or AIDS, Cancer or other terminal illnesses
Criminal behavior
Poverty
Alternative Lifestyles/sexual orientation
Wheelchair bound
Gender
Obesity

All our Consumers belong to
stigmatized groups!

Stigmatized People
Consumers and their families
can’t navigate the bureaucracy
even if resources are there.
It’s too frustrating!

Use People First Language
“I am more than my
illness….Don’t call me
“the schizophrenic,
“the addict” or
“the retard.”

As human beings, we have many
similarities…..
But, who we really are, is often
derived from our original family of origin
and our current lifestyle.

The Bottom Line:
People are different, even within
their own culture!
These differences matter when
planning and providing services.

National Mental Health
Association
“For Mental Health consumers, both
access to the services and the effectiveness
of the care they receive are greatly affected
by the degree to which the delivery system
is“culturally competent.”

Some important definitions
Related to Cultural Competency

Culture

from King,et. al

The Office of Special Programs, U.S. Dept. of Education

“The integrated patterns of human
behavior that includes thoughts,
communications, actions, customs,
beliefs,values, and institutions of
racial, ethnic, religious, or social
groups.”

Cultural Sensitivity
An awareness and respect of a
person’s cultural beliefs and
values.
Culhane-Pera, et .al

Cultural Competency
 Skills

(that translate into)
 Behaviors, Practices, Attitudes, and
 Policies
That enable an individual, agency, or
system to effectively serve culturally
diverse communities.
from The Asian Health Coalition of Illinois

Here at Hill Country MHDDC
Consumers are very diverse in their
language and culture.

61% of our Consumers are
Caucasian Americans
Many have German
backgrounds.

Our Consumers are …..

n
1% NativeAmerican

33% Hispanic
1% Asian

3% African
American

1% are “Others”

Consumers Have Many
Different Lifestyles

Lifestyles

They have many different
beliefs.

Can We Communicate?
Think Language first!
 Do we need an interpreter?
 Communicate respectfully.
 Be sensitive to the consumer and the family.
 Consider your dress, tone of voice, eye contact,
location, seating arrangement, privacy, etc.


Is our approach culturally
appropriate?
“What do you call your problem?”
“What name does it have?”
“What do you think caused your problem?”
“Why do you think it started when it did?”
From Arthur Kleinman’s question protocol in“Culture,Illness, and Care:
Clinical Lessons from Anthropologic and Cross Cultural Research”,
Ann.Intern.Med. 1978:Vol.88, pg.251-258

Important Issues to Consider…





Impact of religion.
How are women, men, elders, and children
treated in their culture?
Is there domestic violence?
Ethnic minorities generally underutilize
outpatient services, although African-Americans
are over-represented in inpatient setting.

Diagnosis






Minorities with Bipolar Disorder are often
diagnosed with schizophrenia. (Mukherjee,et al)
African Americans are over diagnosed with
schizophrenia and under diagnosed with mood
disorders. (Bell )
A mental health consumer’s addictions may not
be treated.
The elderly may not be assessed for substance
abuse or alcoholism.

Diagnosis
A person with a primary addiction problem
might not be treated for a co-occurring mental
illness.
 Learning disabilities may not be identified in
individuals with mental illness or substance
abuse.
 A person with mental retardation may not be
treated for mental illness or substance abuse.


Diagnosis
Post Traumatic Stress Disorder is often
undiagnosed in people suffering from
Domestic Abuse or other trauma.
 Children who are witnessing or are
victims of domestic abuse or another
trauma, may be misdiagnosed with
Attention Deficit Hyperactivity Disorder.


Medication Differences





Asians and Hispanics need lower doses of antipsychotics.
African Americans use the same doses of antipsychotics, but lower doses of lithium.
The elderly need lower dosages of medications.
Thus, metabolism of drugs varies with age and
ethnicity and is critical in prescribing
medications.

From “Making Room for Culture in Psychiatry” by Lin, et al.

Pain Tolerance
Men and women tolerate pain differently.
 Cultures tolerate pain differently.
 People with addictions develop a
hypersensitivity to pain.
 In certain cultures, self-inflicted pain is a
part of a religious experience.


Religion





Religious beliefs shape how the world is viewed.
Is illness a punishment? The devil’s work? An
evil spell? Bad karma?
For Hispanics, the curandero is a trusted healer.
For Lakota Sioux, the ritual Vision Quest,
praying and fasting at a holy site is life
changing.

Remember there are as many
differences
Between individuals in the same
culture as there are between
individuals in different cultures!

Two African American
families, one lesbian
and the other, multi-racial.

German Consumers
Suggestions from our Gillespie County MH staff

What generation German?
 Would they feel more comfortable
speaking in German?


A consumer reacting to internal stimuli.

German Consumers
Suggestions from our Gillespie MHC staff in Fredericksburg

They may be resistant to seeking
mental services.
They may be reluctant to take medication.
They may “keep things within the family.”
They are concerned about the stigma.

German Consumers
They may feel it’s a character flaw or a
disgrace.
 They are very concerned about
confidentiality.
 Drinking alcohol is an accepted part of
their culture.
 Teen drinking may be acceptable in their
family.


Hispanic Consumers
from the U.S. Census, 1/23/03 Houston Chronicle

Hispanics are the largest minority group in
the U.S. with 37 million people.
 Texas is approximately 32 percent
Hispanic
 11.5 % African American,
 3.3% Other
 53.1% Anglo


Treatment Issues for Hispanic
Consumers
Do we need an interpreter?
 Is the person Tejano or from Mexico?
What generation Hispanic?
Is the person using a curandero?

Treatment issues for Hispanic
Consumers
Hallucinations are natural in their
religion.
 Hearing the voice of a loved one or having
hallucinations might be an expectations
when celebrating the Day of the Dead.
 Hispanic families are patriarchal.


Hispanic Consumers and
The Day of the Dead
A man is dressed in a skeleton
costume to portray death
in a celebration of
Dia de los Muertos,
The Day of the Dead.
People visit the graves of their
dead relatives to honor them.

Native Americans

Treatment Issues for Native
American Consumers
 Impact of racism,unemployment,and poverty.
 Coping with reservation life and
assimilation in mainstream culture.
 Consider the obesity, diabetes,
hypertension, and alcoholism in adults
and fetal alcohol syndrome in children.
 High use of native healers in the Southwest.

African Americans

African Americans
from the Houston Chronicle, 1/23/03

There are 36.2 million Americans who
identify themselves as “black only.”
 37.7 million identify themselves as “black
and at least one other race.”
 11.5% of Texans are African Americans.


Treatment Issues for African
American
Assess for co-occurring substance use
disorders and alcoholism.
 Address complications of obesity,
hypertension, diabetes,congestive heart
failure, asthma, and cancer.
 Sickle cell anemia is another illness
specific to African Americans.


Treatment Issues for African
Americans
Matriarchy; Mom or grandmother are the
dominant family figures.
 Lack of male role models and intact
families.
 Extended family or the Church may be
supports.


Treatment Issues for African
Americans


There is discrimination within their own
group based on skin color, hair texture,
class, values, etc.

Treatment Issues for Asians

Asians rarely seek help until its very severe.
Asians have extremely low admissions to state hospitals.
Mental illness is considered shameful. It’s hidden.
Is an interpreter needed?

Treatment Issues for Asians
Focus on physical symptoms.
 Asians are sensitive to medication.
 Give ½ the standard dose.
 Asians may use traditional healers and
herbal medicine.
 Asians may “flush” when drinking
alcohol.


Asian Consumers

Acupuncture has been used to treat
pain, schizophrenia, depression, and addictions.

Treatment Issues for Asians
Asian Cultures are patriarchal.
 The males in the family have the authority.
 Asians are more formal and inhibited in
their social behavior.


Older Adults

Treatment Issues for Older
Adults
Are they aware they need help?

Treatment Issues for Older
Adults
Is their mental illness caused by medicine?
 Do their medical problems cause or
complicate their mental illness?
 Is there Elder Abuse?


Gay Men and Lesbian Women
May struggle with homophobia and“being in the
closet” at work and with their families.
Gay people may want marriage, children, partner
benefits, etc., but may endure legal barriers.

Gay and Lesbian Women
Gay people often have specific health
issues related to their sexual practices.
 HIV, AIDS and STD’s are still concerns
with Gay men.
 People may be grieving the death of a
partner or friends who’ve died from AIDS,
or coping with living with AIDS or being
HIV+ themselves.


Treatment Issues for Gay and
Lesbians
Explore childhood abuse issues and
Domestic Violence..
 Assess for substance use and alcoholism.
 Sex enhancing drug use may be common
among some gay men.


Physically Challenged
Can they get to treatment?
Deal with their frustration and depression
Re: their disability.
 Do they need vocational assistance?

Mentally Challenged

Treatment Issues of Mentally
Challenged
They need to have meaningful activity
and purpose in their lives.
 They need to feel acknowledged and
appreciated.
 They need safety, structure, and security.
 Lack of continuity can cause crisis!
 They may need vocational assistance.


Winona Ryder

December 12, 2001,
Winona Ryder shoplifted
$5,560.40 designer items
from Saks Fifth Avenue in
Beverley Hills.

Twice an Academy
Award Nominated
actress

She had the following 8 drugs in
her possession:
Liquid demerol
 Liquid Diazepam
 Vicodin
 Percodan
 Valium
 Morphine sulfate
 Endocet (containing Oxycodone)


Patterns of Drug Use are highly
Regional.
 Drugs,

routes of administration, street
names, patterns of use, and drug
combinations may differ greatly, not
only between individuals from
different cultures, but different parts
of the country or even different parts
of the city.

Drugs of Choice
Native Americans-alcohol
 Asians-gambling, work
 Gay Men-stimulants, amyl nitrate, ecstasy
 “Rich”-prescription drugs, Internet porn
 M.D.’s –Vicodin


Drugs of Choice
Young adults-marijuana, cigarettes
 Geriatrics-alcohol, pills
 Sex Workers-crack cocaine, IV speedballs
 Screen mentally retarded for abuse too!


How Do We Best Serve Our
Consumers?




Examine own stereotypes.
Build trust.
Use People First language!

How do we best serve our
consumers?
Pronounce the person’s name correctly.
 Get an interpreter, if necessary.
 Educate yourself from the consumer, his
family, co-workers, etc.
 Remember differences do matter!



Slide 16

Cultural Competence
Integrating Differences
into Community Services

Objectives
Understand Stigma.
 Understand Culture Competency.
 Learn Culturally competent care for
people with Mental Health, Mental
Retardation and Addictions.


We live in an world
which often separates us.
Racism
 Sexism
 Ageism
 Feminism
 Classism
 Atheism


“Different” people are
“Stigmatized”

Mentally retarded inmates in a sanitorium in Germany

Stigma
Definitions from the U. of Chicago PSR Training Manual

“Stigmas are negative attitudes about a
group that lead to depriving them of
some fair opportunities.”

Stigma is related to…..
Stereotypes
Prejudice
Discrimination

Stereotypes
from The Asian Health Coalition of Illinois

Stereotypes are exaggerated beliefs
or fixed ideas about a person or
group which is held by people and
sustained by selective perception and
selective forgetting.

Prejudice
from The Asian Health Coalition of Illinois

Prejudice is a preconceived idea or
negative attitude formed before the
facts are known and sustained over
generalizations. A bias without
reason, resisting all evidence…

Discrimination
from The Asian Health Coalition of Illinois

Discrimination refers to treatment in
favor or against a person based on
the group to which that person
belongs and not on merit.

Stigmatized People…..
Experience being stereotyped and
are often the object of
discrimination and prejudice.

People are often stigmatized by:













Mental Illness
Mental Retardation
Physical Disability (including blindness, deafness)
Alcoholism /and or Drug Addiction
HIV or AIDS, Cancer or other terminal illnesses
Criminal behavior
Poverty
Alternative Lifestyles/sexual orientation
Wheelchair bound
Gender
Obesity

All our Consumers belong to
stigmatized groups!

Stigmatized People
Consumers and their families
can’t navigate the bureaucracy
even if resources are there.
It’s too frustrating!

Use People First Language
“I am more than my
illness….Don’t call me
“the schizophrenic,
“the addict” or
“the retard.”

As human beings, we have many
similarities…..
But, who we really are, is often
derived from our original family of origin
and our current lifestyle.

The Bottom Line:
People are different, even within
their own culture!
These differences matter when
planning and providing services.

National Mental Health
Association
“For Mental Health consumers, both
access to the services and the effectiveness
of the care they receive are greatly affected
by the degree to which the delivery system
is“culturally competent.”

Some important definitions
Related to Cultural Competency

Culture

from King,et. al

The Office of Special Programs, U.S. Dept. of Education

“The integrated patterns of human
behavior that includes thoughts,
communications, actions, customs,
beliefs,values, and institutions of
racial, ethnic, religious, or social
groups.”

Cultural Sensitivity
An awareness and respect of a
person’s cultural beliefs and
values.
Culhane-Pera, et .al

Cultural Competency
 Skills

(that translate into)
 Behaviors, Practices, Attitudes, and
 Policies
That enable an individual, agency, or
system to effectively serve culturally
diverse communities.
from The Asian Health Coalition of Illinois

Here at Hill Country MHDDC
Consumers are very diverse in their
language and culture.

61% of our Consumers are
Caucasian Americans
Many have German
backgrounds.

Our Consumers are …..

n
1% NativeAmerican

33% Hispanic
1% Asian

3% African
American

1% are “Others”

Consumers Have Many
Different Lifestyles

Lifestyles

They have many different
beliefs.

Can We Communicate?
Think Language first!
 Do we need an interpreter?
 Communicate respectfully.
 Be sensitive to the consumer and the family.
 Consider your dress, tone of voice, eye contact,
location, seating arrangement, privacy, etc.


Is our approach culturally
appropriate?
“What do you call your problem?”
“What name does it have?”
“What do you think caused your problem?”
“Why do you think it started when it did?”
From Arthur Kleinman’s question protocol in“Culture,Illness, and Care:
Clinical Lessons from Anthropologic and Cross Cultural Research”,
Ann.Intern.Med. 1978:Vol.88, pg.251-258

Important Issues to Consider…





Impact of religion.
How are women, men, elders, and children
treated in their culture?
Is there domestic violence?
Ethnic minorities generally underutilize
outpatient services, although African-Americans
are over-represented in inpatient setting.

Diagnosis






Minorities with Bipolar Disorder are often
diagnosed with schizophrenia. (Mukherjee,et al)
African Americans are over diagnosed with
schizophrenia and under diagnosed with mood
disorders. (Bell )
A mental health consumer’s addictions may not
be treated.
The elderly may not be assessed for substance
abuse or alcoholism.

Diagnosis
A person with a primary addiction problem
might not be treated for a co-occurring mental
illness.
 Learning disabilities may not be identified in
individuals with mental illness or substance
abuse.
 A person with mental retardation may not be
treated for mental illness or substance abuse.


Diagnosis
Post Traumatic Stress Disorder is often
undiagnosed in people suffering from
Domestic Abuse or other trauma.
 Children who are witnessing or are
victims of domestic abuse or another
trauma, may be misdiagnosed with
Attention Deficit Hyperactivity Disorder.


Medication Differences





Asians and Hispanics need lower doses of antipsychotics.
African Americans use the same doses of antipsychotics, but lower doses of lithium.
The elderly need lower dosages of medications.
Thus, metabolism of drugs varies with age and
ethnicity and is critical in prescribing
medications.

From “Making Room for Culture in Psychiatry” by Lin, et al.

Pain Tolerance
Men and women tolerate pain differently.
 Cultures tolerate pain differently.
 People with addictions develop a
hypersensitivity to pain.
 In certain cultures, self-inflicted pain is a
part of a religious experience.


Religion





Religious beliefs shape how the world is viewed.
Is illness a punishment? The devil’s work? An
evil spell? Bad karma?
For Hispanics, the curandero is a trusted healer.
For Lakota Sioux, the ritual Vision Quest,
praying and fasting at a holy site is life
changing.

Remember there are as many
differences
Between individuals in the same
culture as there are between
individuals in different cultures!

Two African American
families, one lesbian
and the other, multi-racial.

German Consumers
Suggestions from our Gillespie County MH staff

What generation German?
 Would they feel more comfortable
speaking in German?


A consumer reacting to internal stimuli.

German Consumers
Suggestions from our Gillespie MHC staff in Fredericksburg

They may be resistant to seeking
mental services.
They may be reluctant to take medication.
They may “keep things within the family.”
They are concerned about the stigma.

German Consumers
They may feel it’s a character flaw or a
disgrace.
 They are very concerned about
confidentiality.
 Drinking alcohol is an accepted part of
their culture.
 Teen drinking may be acceptable in their
family.


Hispanic Consumers
from the U.S. Census, 1/23/03 Houston Chronicle

Hispanics are the largest minority group in
the U.S. with 37 million people.
 Texas is approximately 32 percent
Hispanic
 11.5 % African American,
 3.3% Other
 53.1% Anglo


Treatment Issues for Hispanic
Consumers
Do we need an interpreter?
 Is the person Tejano or from Mexico?
What generation Hispanic?
Is the person using a curandero?

Treatment issues for Hispanic
Consumers
Hallucinations are natural in their
religion.
 Hearing the voice of a loved one or having
hallucinations might be an expectations
when celebrating the Day of the Dead.
 Hispanic families are patriarchal.


Hispanic Consumers and
The Day of the Dead
A man is dressed in a skeleton
costume to portray death
in a celebration of
Dia de los Muertos,
The Day of the Dead.
People visit the graves of their
dead relatives to honor them.

Native Americans

Treatment Issues for Native
American Consumers
 Impact of racism,unemployment,and poverty.
 Coping with reservation life and
assimilation in mainstream culture.
 Consider the obesity, diabetes,
hypertension, and alcoholism in adults
and fetal alcohol syndrome in children.
 High use of native healers in the Southwest.

African Americans

African Americans
from the Houston Chronicle, 1/23/03

There are 36.2 million Americans who
identify themselves as “black only.”
 37.7 million identify themselves as “black
and at least one other race.”
 11.5% of Texans are African Americans.


Treatment Issues for African
American
Assess for co-occurring substance use
disorders and alcoholism.
 Address complications of obesity,
hypertension, diabetes,congestive heart
failure, asthma, and cancer.
 Sickle cell anemia is another illness
specific to African Americans.


Treatment Issues for African
Americans
Matriarchy; Mom or grandmother are the
dominant family figures.
 Lack of male role models and intact
families.
 Extended family or the Church may be
supports.


Treatment Issues for African
Americans


There is discrimination within their own
group based on skin color, hair texture,
class, values, etc.

Treatment Issues for Asians

Asians rarely seek help until its very severe.
Asians have extremely low admissions to state hospitals.
Mental illness is considered shameful. It’s hidden.
Is an interpreter needed?

Treatment Issues for Asians
Focus on physical symptoms.
 Asians are sensitive to medication.
 Give ½ the standard dose.
 Asians may use traditional healers and
herbal medicine.
 Asians may “flush” when drinking
alcohol.


Asian Consumers

Acupuncture has been used to treat
pain, schizophrenia, depression, and addictions.

Treatment Issues for Asians
Asian Cultures are patriarchal.
 The males in the family have the authority.
 Asians are more formal and inhibited in
their social behavior.


Older Adults

Treatment Issues for Older
Adults
Are they aware they need help?

Treatment Issues for Older
Adults
Is their mental illness caused by medicine?
 Do their medical problems cause or
complicate their mental illness?
 Is there Elder Abuse?


Gay Men and Lesbian Women
May struggle with homophobia and“being in the
closet” at work and with their families.
Gay people may want marriage, children, partner
benefits, etc., but may endure legal barriers.

Gay and Lesbian Women
Gay people often have specific health
issues related to their sexual practices.
 HIV, AIDS and STD’s are still concerns
with Gay men.
 People may be grieving the death of a
partner or friends who’ve died from AIDS,
or coping with living with AIDS or being
HIV+ themselves.


Treatment Issues for Gay and
Lesbians
Explore childhood abuse issues and
Domestic Violence..
 Assess for substance use and alcoholism.
 Sex enhancing drug use may be common
among some gay men.


Physically Challenged
Can they get to treatment?
Deal with their frustration and depression
Re: their disability.
 Do they need vocational assistance?

Mentally Challenged

Treatment Issues of Mentally
Challenged
They need to have meaningful activity
and purpose in their lives.
 They need to feel acknowledged and
appreciated.
 They need safety, structure, and security.
 Lack of continuity can cause crisis!
 They may need vocational assistance.


Winona Ryder

December 12, 2001,
Winona Ryder shoplifted
$5,560.40 designer items
from Saks Fifth Avenue in
Beverley Hills.

Twice an Academy
Award Nominated
actress

She had the following 8 drugs in
her possession:
Liquid demerol
 Liquid Diazepam
 Vicodin
 Percodan
 Valium
 Morphine sulfate
 Endocet (containing Oxycodone)


Patterns of Drug Use are highly
Regional.
 Drugs,

routes of administration, street
names, patterns of use, and drug
combinations may differ greatly, not
only between individuals from
different cultures, but different parts
of the country or even different parts
of the city.

Drugs of Choice
Native Americans-alcohol
 Asians-gambling, work
 Gay Men-stimulants, amyl nitrate, ecstasy
 “Rich”-prescription drugs, Internet porn
 M.D.’s –Vicodin


Drugs of Choice
Young adults-marijuana, cigarettes
 Geriatrics-alcohol, pills
 Sex Workers-crack cocaine, IV speedballs
 Screen mentally retarded for abuse too!


How Do We Best Serve Our
Consumers?




Examine own stereotypes.
Build trust.
Use People First language!

How do we best serve our
consumers?
Pronounce the person’s name correctly.
 Get an interpreter, if necessary.
 Educate yourself from the consumer, his
family, co-workers, etc.
 Remember differences do matter!



Slide 17

Cultural Competence
Integrating Differences
into Community Services

Objectives
Understand Stigma.
 Understand Culture Competency.
 Learn Culturally competent care for
people with Mental Health, Mental
Retardation and Addictions.


We live in an world
which often separates us.
Racism
 Sexism
 Ageism
 Feminism
 Classism
 Atheism


“Different” people are
“Stigmatized”

Mentally retarded inmates in a sanitorium in Germany

Stigma
Definitions from the U. of Chicago PSR Training Manual

“Stigmas are negative attitudes about a
group that lead to depriving them of
some fair opportunities.”

Stigma is related to…..
Stereotypes
Prejudice
Discrimination

Stereotypes
from The Asian Health Coalition of Illinois

Stereotypes are exaggerated beliefs
or fixed ideas about a person or
group which is held by people and
sustained by selective perception and
selective forgetting.

Prejudice
from The Asian Health Coalition of Illinois

Prejudice is a preconceived idea or
negative attitude formed before the
facts are known and sustained over
generalizations. A bias without
reason, resisting all evidence…

Discrimination
from The Asian Health Coalition of Illinois

Discrimination refers to treatment in
favor or against a person based on
the group to which that person
belongs and not on merit.

Stigmatized People…..
Experience being stereotyped and
are often the object of
discrimination and prejudice.

People are often stigmatized by:













Mental Illness
Mental Retardation
Physical Disability (including blindness, deafness)
Alcoholism /and or Drug Addiction
HIV or AIDS, Cancer or other terminal illnesses
Criminal behavior
Poverty
Alternative Lifestyles/sexual orientation
Wheelchair bound
Gender
Obesity

All our Consumers belong to
stigmatized groups!

Stigmatized People
Consumers and their families
can’t navigate the bureaucracy
even if resources are there.
It’s too frustrating!

Use People First Language
“I am more than my
illness….Don’t call me
“the schizophrenic,
“the addict” or
“the retard.”

As human beings, we have many
similarities…..
But, who we really are, is often
derived from our original family of origin
and our current lifestyle.

The Bottom Line:
People are different, even within
their own culture!
These differences matter when
planning and providing services.

National Mental Health
Association
“For Mental Health consumers, both
access to the services and the effectiveness
of the care they receive are greatly affected
by the degree to which the delivery system
is“culturally competent.”

Some important definitions
Related to Cultural Competency

Culture

from King,et. al

The Office of Special Programs, U.S. Dept. of Education

“The integrated patterns of human
behavior that includes thoughts,
communications, actions, customs,
beliefs,values, and institutions of
racial, ethnic, religious, or social
groups.”

Cultural Sensitivity
An awareness and respect of a
person’s cultural beliefs and
values.
Culhane-Pera, et .al

Cultural Competency
 Skills

(that translate into)
 Behaviors, Practices, Attitudes, and
 Policies
That enable an individual, agency, or
system to effectively serve culturally
diverse communities.
from The Asian Health Coalition of Illinois

Here at Hill Country MHDDC
Consumers are very diverse in their
language and culture.

61% of our Consumers are
Caucasian Americans
Many have German
backgrounds.

Our Consumers are …..

n
1% NativeAmerican

33% Hispanic
1% Asian

3% African
American

1% are “Others”

Consumers Have Many
Different Lifestyles

Lifestyles

They have many different
beliefs.

Can We Communicate?
Think Language first!
 Do we need an interpreter?
 Communicate respectfully.
 Be sensitive to the consumer and the family.
 Consider your dress, tone of voice, eye contact,
location, seating arrangement, privacy, etc.


Is our approach culturally
appropriate?
“What do you call your problem?”
“What name does it have?”
“What do you think caused your problem?”
“Why do you think it started when it did?”
From Arthur Kleinman’s question protocol in“Culture,Illness, and Care:
Clinical Lessons from Anthropologic and Cross Cultural Research”,
Ann.Intern.Med. 1978:Vol.88, pg.251-258

Important Issues to Consider…





Impact of religion.
How are women, men, elders, and children
treated in their culture?
Is there domestic violence?
Ethnic minorities generally underutilize
outpatient services, although African-Americans
are over-represented in inpatient setting.

Diagnosis






Minorities with Bipolar Disorder are often
diagnosed with schizophrenia. (Mukherjee,et al)
African Americans are over diagnosed with
schizophrenia and under diagnosed with mood
disorders. (Bell )
A mental health consumer’s addictions may not
be treated.
The elderly may not be assessed for substance
abuse or alcoholism.

Diagnosis
A person with a primary addiction problem
might not be treated for a co-occurring mental
illness.
 Learning disabilities may not be identified in
individuals with mental illness or substance
abuse.
 A person with mental retardation may not be
treated for mental illness or substance abuse.


Diagnosis
Post Traumatic Stress Disorder is often
undiagnosed in people suffering from
Domestic Abuse or other trauma.
 Children who are witnessing or are
victims of domestic abuse or another
trauma, may be misdiagnosed with
Attention Deficit Hyperactivity Disorder.


Medication Differences





Asians and Hispanics need lower doses of antipsychotics.
African Americans use the same doses of antipsychotics, but lower doses of lithium.
The elderly need lower dosages of medications.
Thus, metabolism of drugs varies with age and
ethnicity and is critical in prescribing
medications.

From “Making Room for Culture in Psychiatry” by Lin, et al.

Pain Tolerance
Men and women tolerate pain differently.
 Cultures tolerate pain differently.
 People with addictions develop a
hypersensitivity to pain.
 In certain cultures, self-inflicted pain is a
part of a religious experience.


Religion





Religious beliefs shape how the world is viewed.
Is illness a punishment? The devil’s work? An
evil spell? Bad karma?
For Hispanics, the curandero is a trusted healer.
For Lakota Sioux, the ritual Vision Quest,
praying and fasting at a holy site is life
changing.

Remember there are as many
differences
Between individuals in the same
culture as there are between
individuals in different cultures!

Two African American
families, one lesbian
and the other, multi-racial.

German Consumers
Suggestions from our Gillespie County MH staff

What generation German?
 Would they feel more comfortable
speaking in German?


A consumer reacting to internal stimuli.

German Consumers
Suggestions from our Gillespie MHC staff in Fredericksburg

They may be resistant to seeking
mental services.
They may be reluctant to take medication.
They may “keep things within the family.”
They are concerned about the stigma.

German Consumers
They may feel it’s a character flaw or a
disgrace.
 They are very concerned about
confidentiality.
 Drinking alcohol is an accepted part of
their culture.
 Teen drinking may be acceptable in their
family.


Hispanic Consumers
from the U.S. Census, 1/23/03 Houston Chronicle

Hispanics are the largest minority group in
the U.S. with 37 million people.
 Texas is approximately 32 percent
Hispanic
 11.5 % African American,
 3.3% Other
 53.1% Anglo


Treatment Issues for Hispanic
Consumers
Do we need an interpreter?
 Is the person Tejano or from Mexico?
What generation Hispanic?
Is the person using a curandero?

Treatment issues for Hispanic
Consumers
Hallucinations are natural in their
religion.
 Hearing the voice of a loved one or having
hallucinations might be an expectations
when celebrating the Day of the Dead.
 Hispanic families are patriarchal.


Hispanic Consumers and
The Day of the Dead
A man is dressed in a skeleton
costume to portray death
in a celebration of
Dia de los Muertos,
The Day of the Dead.
People visit the graves of their
dead relatives to honor them.

Native Americans

Treatment Issues for Native
American Consumers
 Impact of racism,unemployment,and poverty.
 Coping with reservation life and
assimilation in mainstream culture.
 Consider the obesity, diabetes,
hypertension, and alcoholism in adults
and fetal alcohol syndrome in children.
 High use of native healers in the Southwest.

African Americans

African Americans
from the Houston Chronicle, 1/23/03

There are 36.2 million Americans who
identify themselves as “black only.”
 37.7 million identify themselves as “black
and at least one other race.”
 11.5% of Texans are African Americans.


Treatment Issues for African
American
Assess for co-occurring substance use
disorders and alcoholism.
 Address complications of obesity,
hypertension, diabetes,congestive heart
failure, asthma, and cancer.
 Sickle cell anemia is another illness
specific to African Americans.


Treatment Issues for African
Americans
Matriarchy; Mom or grandmother are the
dominant family figures.
 Lack of male role models and intact
families.
 Extended family or the Church may be
supports.


Treatment Issues for African
Americans


There is discrimination within their own
group based on skin color, hair texture,
class, values, etc.

Treatment Issues for Asians

Asians rarely seek help until its very severe.
Asians have extremely low admissions to state hospitals.
Mental illness is considered shameful. It’s hidden.
Is an interpreter needed?

Treatment Issues for Asians
Focus on physical symptoms.
 Asians are sensitive to medication.
 Give ½ the standard dose.
 Asians may use traditional healers and
herbal medicine.
 Asians may “flush” when drinking
alcohol.


Asian Consumers

Acupuncture has been used to treat
pain, schizophrenia, depression, and addictions.

Treatment Issues for Asians
Asian Cultures are patriarchal.
 The males in the family have the authority.
 Asians are more formal and inhibited in
their social behavior.


Older Adults

Treatment Issues for Older
Adults
Are they aware they need help?

Treatment Issues for Older
Adults
Is their mental illness caused by medicine?
 Do their medical problems cause or
complicate their mental illness?
 Is there Elder Abuse?


Gay Men and Lesbian Women
May struggle with homophobia and“being in the
closet” at work and with their families.
Gay people may want marriage, children, partner
benefits, etc., but may endure legal barriers.

Gay and Lesbian Women
Gay people often have specific health
issues related to their sexual practices.
 HIV, AIDS and STD’s are still concerns
with Gay men.
 People may be grieving the death of a
partner or friends who’ve died from AIDS,
or coping with living with AIDS or being
HIV+ themselves.


Treatment Issues for Gay and
Lesbians
Explore childhood abuse issues and
Domestic Violence..
 Assess for substance use and alcoholism.
 Sex enhancing drug use may be common
among some gay men.


Physically Challenged
Can they get to treatment?
Deal with their frustration and depression
Re: their disability.
 Do they need vocational assistance?

Mentally Challenged

Treatment Issues of Mentally
Challenged
They need to have meaningful activity
and purpose in their lives.
 They need to feel acknowledged and
appreciated.
 They need safety, structure, and security.
 Lack of continuity can cause crisis!
 They may need vocational assistance.


Winona Ryder

December 12, 2001,
Winona Ryder shoplifted
$5,560.40 designer items
from Saks Fifth Avenue in
Beverley Hills.

Twice an Academy
Award Nominated
actress

She had the following 8 drugs in
her possession:
Liquid demerol
 Liquid Diazepam
 Vicodin
 Percodan
 Valium
 Morphine sulfate
 Endocet (containing Oxycodone)


Patterns of Drug Use are highly
Regional.
 Drugs,

routes of administration, street
names, patterns of use, and drug
combinations may differ greatly, not
only between individuals from
different cultures, but different parts
of the country or even different parts
of the city.

Drugs of Choice
Native Americans-alcohol
 Asians-gambling, work
 Gay Men-stimulants, amyl nitrate, ecstasy
 “Rich”-prescription drugs, Internet porn
 M.D.’s –Vicodin


Drugs of Choice
Young adults-marijuana, cigarettes
 Geriatrics-alcohol, pills
 Sex Workers-crack cocaine, IV speedballs
 Screen mentally retarded for abuse too!


How Do We Best Serve Our
Consumers?




Examine own stereotypes.
Build trust.
Use People First language!

How do we best serve our
consumers?
Pronounce the person’s name correctly.
 Get an interpreter, if necessary.
 Educate yourself from the consumer, his
family, co-workers, etc.
 Remember differences do matter!



Slide 18

Cultural Competence
Integrating Differences
into Community Services

Objectives
Understand Stigma.
 Understand Culture Competency.
 Learn Culturally competent care for
people with Mental Health, Mental
Retardation and Addictions.


We live in an world
which often separates us.
Racism
 Sexism
 Ageism
 Feminism
 Classism
 Atheism


“Different” people are
“Stigmatized”

Mentally retarded inmates in a sanitorium in Germany

Stigma
Definitions from the U. of Chicago PSR Training Manual

“Stigmas are negative attitudes about a
group that lead to depriving them of
some fair opportunities.”

Stigma is related to…..
Stereotypes
Prejudice
Discrimination

Stereotypes
from The Asian Health Coalition of Illinois

Stereotypes are exaggerated beliefs
or fixed ideas about a person or
group which is held by people and
sustained by selective perception and
selective forgetting.

Prejudice
from The Asian Health Coalition of Illinois

Prejudice is a preconceived idea or
negative attitude formed before the
facts are known and sustained over
generalizations. A bias without
reason, resisting all evidence…

Discrimination
from The Asian Health Coalition of Illinois

Discrimination refers to treatment in
favor or against a person based on
the group to which that person
belongs and not on merit.

Stigmatized People…..
Experience being stereotyped and
are often the object of
discrimination and prejudice.

People are often stigmatized by:













Mental Illness
Mental Retardation
Physical Disability (including blindness, deafness)
Alcoholism /and or Drug Addiction
HIV or AIDS, Cancer or other terminal illnesses
Criminal behavior
Poverty
Alternative Lifestyles/sexual orientation
Wheelchair bound
Gender
Obesity

All our Consumers belong to
stigmatized groups!

Stigmatized People
Consumers and their families
can’t navigate the bureaucracy
even if resources are there.
It’s too frustrating!

Use People First Language
“I am more than my
illness….Don’t call me
“the schizophrenic,
“the addict” or
“the retard.”

As human beings, we have many
similarities…..
But, who we really are, is often
derived from our original family of origin
and our current lifestyle.

The Bottom Line:
People are different, even within
their own culture!
These differences matter when
planning and providing services.

National Mental Health
Association
“For Mental Health consumers, both
access to the services and the effectiveness
of the care they receive are greatly affected
by the degree to which the delivery system
is“culturally competent.”

Some important definitions
Related to Cultural Competency

Culture

from King,et. al

The Office of Special Programs, U.S. Dept. of Education

“The integrated patterns of human
behavior that includes thoughts,
communications, actions, customs,
beliefs,values, and institutions of
racial, ethnic, religious, or social
groups.”

Cultural Sensitivity
An awareness and respect of a
person’s cultural beliefs and
values.
Culhane-Pera, et .al

Cultural Competency
 Skills

(that translate into)
 Behaviors, Practices, Attitudes, and
 Policies
That enable an individual, agency, or
system to effectively serve culturally
diverse communities.
from The Asian Health Coalition of Illinois

Here at Hill Country MHDDC
Consumers are very diverse in their
language and culture.

61% of our Consumers are
Caucasian Americans
Many have German
backgrounds.

Our Consumers are …..

n
1% NativeAmerican

33% Hispanic
1% Asian

3% African
American

1% are “Others”

Consumers Have Many
Different Lifestyles

Lifestyles

They have many different
beliefs.

Can We Communicate?
Think Language first!
 Do we need an interpreter?
 Communicate respectfully.
 Be sensitive to the consumer and the family.
 Consider your dress, tone of voice, eye contact,
location, seating arrangement, privacy, etc.


Is our approach culturally
appropriate?
“What do you call your problem?”
“What name does it have?”
“What do you think caused your problem?”
“Why do you think it started when it did?”
From Arthur Kleinman’s question protocol in“Culture,Illness, and Care:
Clinical Lessons from Anthropologic and Cross Cultural Research”,
Ann.Intern.Med. 1978:Vol.88, pg.251-258

Important Issues to Consider…





Impact of religion.
How are women, men, elders, and children
treated in their culture?
Is there domestic violence?
Ethnic minorities generally underutilize
outpatient services, although African-Americans
are over-represented in inpatient setting.

Diagnosis






Minorities with Bipolar Disorder are often
diagnosed with schizophrenia. (Mukherjee,et al)
African Americans are over diagnosed with
schizophrenia and under diagnosed with mood
disorders. (Bell )
A mental health consumer’s addictions may not
be treated.
The elderly may not be assessed for substance
abuse or alcoholism.

Diagnosis
A person with a primary addiction problem
might not be treated for a co-occurring mental
illness.
 Learning disabilities may not be identified in
individuals with mental illness or substance
abuse.
 A person with mental retardation may not be
treated for mental illness or substance abuse.


Diagnosis
Post Traumatic Stress Disorder is often
undiagnosed in people suffering from
Domestic Abuse or other trauma.
 Children who are witnessing or are
victims of domestic abuse or another
trauma, may be misdiagnosed with
Attention Deficit Hyperactivity Disorder.


Medication Differences





Asians and Hispanics need lower doses of antipsychotics.
African Americans use the same doses of antipsychotics, but lower doses of lithium.
The elderly need lower dosages of medications.
Thus, metabolism of drugs varies with age and
ethnicity and is critical in prescribing
medications.

From “Making Room for Culture in Psychiatry” by Lin, et al.

Pain Tolerance
Men and women tolerate pain differently.
 Cultures tolerate pain differently.
 People with addictions develop a
hypersensitivity to pain.
 In certain cultures, self-inflicted pain is a
part of a religious experience.


Religion





Religious beliefs shape how the world is viewed.
Is illness a punishment? The devil’s work? An
evil spell? Bad karma?
For Hispanics, the curandero is a trusted healer.
For Lakota Sioux, the ritual Vision Quest,
praying and fasting at a holy site is life
changing.

Remember there are as many
differences
Between individuals in the same
culture as there are between
individuals in different cultures!

Two African American
families, one lesbian
and the other, multi-racial.

German Consumers
Suggestions from our Gillespie County MH staff

What generation German?
 Would they feel more comfortable
speaking in German?


A consumer reacting to internal stimuli.

German Consumers
Suggestions from our Gillespie MHC staff in Fredericksburg

They may be resistant to seeking
mental services.
They may be reluctant to take medication.
They may “keep things within the family.”
They are concerned about the stigma.

German Consumers
They may feel it’s a character flaw or a
disgrace.
 They are very concerned about
confidentiality.
 Drinking alcohol is an accepted part of
their culture.
 Teen drinking may be acceptable in their
family.


Hispanic Consumers
from the U.S. Census, 1/23/03 Houston Chronicle

Hispanics are the largest minority group in
the U.S. with 37 million people.
 Texas is approximately 32 percent
Hispanic
 11.5 % African American,
 3.3% Other
 53.1% Anglo


Treatment Issues for Hispanic
Consumers
Do we need an interpreter?
 Is the person Tejano or from Mexico?
What generation Hispanic?
Is the person using a curandero?

Treatment issues for Hispanic
Consumers
Hallucinations are natural in their
religion.
 Hearing the voice of a loved one or having
hallucinations might be an expectations
when celebrating the Day of the Dead.
 Hispanic families are patriarchal.


Hispanic Consumers and
The Day of the Dead
A man is dressed in a skeleton
costume to portray death
in a celebration of
Dia de los Muertos,
The Day of the Dead.
People visit the graves of their
dead relatives to honor them.

Native Americans

Treatment Issues for Native
American Consumers
 Impact of racism,unemployment,and poverty.
 Coping with reservation life and
assimilation in mainstream culture.
 Consider the obesity, diabetes,
hypertension, and alcoholism in adults
and fetal alcohol syndrome in children.
 High use of native healers in the Southwest.

African Americans

African Americans
from the Houston Chronicle, 1/23/03

There are 36.2 million Americans who
identify themselves as “black only.”
 37.7 million identify themselves as “black
and at least one other race.”
 11.5% of Texans are African Americans.


Treatment Issues for African
American
Assess for co-occurring substance use
disorders and alcoholism.
 Address complications of obesity,
hypertension, diabetes,congestive heart
failure, asthma, and cancer.
 Sickle cell anemia is another illness
specific to African Americans.


Treatment Issues for African
Americans
Matriarchy; Mom or grandmother are the
dominant family figures.
 Lack of male role models and intact
families.
 Extended family or the Church may be
supports.


Treatment Issues for African
Americans


There is discrimination within their own
group based on skin color, hair texture,
class, values, etc.

Treatment Issues for Asians

Asians rarely seek help until its very severe.
Asians have extremely low admissions to state hospitals.
Mental illness is considered shameful. It’s hidden.
Is an interpreter needed?

Treatment Issues for Asians
Focus on physical symptoms.
 Asians are sensitive to medication.
 Give ½ the standard dose.
 Asians may use traditional healers and
herbal medicine.
 Asians may “flush” when drinking
alcohol.


Asian Consumers

Acupuncture has been used to treat
pain, schizophrenia, depression, and addictions.

Treatment Issues for Asians
Asian Cultures are patriarchal.
 The males in the family have the authority.
 Asians are more formal and inhibited in
their social behavior.


Older Adults

Treatment Issues for Older
Adults
Are they aware they need help?

Treatment Issues for Older
Adults
Is their mental illness caused by medicine?
 Do their medical problems cause or
complicate their mental illness?
 Is there Elder Abuse?


Gay Men and Lesbian Women
May struggle with homophobia and“being in the
closet” at work and with their families.
Gay people may want marriage, children, partner
benefits, etc., but may endure legal barriers.

Gay and Lesbian Women
Gay people often have specific health
issues related to their sexual practices.
 HIV, AIDS and STD’s are still concerns
with Gay men.
 People may be grieving the death of a
partner or friends who’ve died from AIDS,
or coping with living with AIDS or being
HIV+ themselves.


Treatment Issues for Gay and
Lesbians
Explore childhood abuse issues and
Domestic Violence..
 Assess for substance use and alcoholism.
 Sex enhancing drug use may be common
among some gay men.


Physically Challenged
Can they get to treatment?
Deal with their frustration and depression
Re: their disability.
 Do they need vocational assistance?

Mentally Challenged

Treatment Issues of Mentally
Challenged
They need to have meaningful activity
and purpose in their lives.
 They need to feel acknowledged and
appreciated.
 They need safety, structure, and security.
 Lack of continuity can cause crisis!
 They may need vocational assistance.


Winona Ryder

December 12, 2001,
Winona Ryder shoplifted
$5,560.40 designer items
from Saks Fifth Avenue in
Beverley Hills.

Twice an Academy
Award Nominated
actress

She had the following 8 drugs in
her possession:
Liquid demerol
 Liquid Diazepam
 Vicodin
 Percodan
 Valium
 Morphine sulfate
 Endocet (containing Oxycodone)


Patterns of Drug Use are highly
Regional.
 Drugs,

routes of administration, street
names, patterns of use, and drug
combinations may differ greatly, not
only between individuals from
different cultures, but different parts
of the country or even different parts
of the city.

Drugs of Choice
Native Americans-alcohol
 Asians-gambling, work
 Gay Men-stimulants, amyl nitrate, ecstasy
 “Rich”-prescription drugs, Internet porn
 M.D.’s –Vicodin


Drugs of Choice
Young adults-marijuana, cigarettes
 Geriatrics-alcohol, pills
 Sex Workers-crack cocaine, IV speedballs
 Screen mentally retarded for abuse too!


How Do We Best Serve Our
Consumers?




Examine own stereotypes.
Build trust.
Use People First language!

How do we best serve our
consumers?
Pronounce the person’s name correctly.
 Get an interpreter, if necessary.
 Educate yourself from the consumer, his
family, co-workers, etc.
 Remember differences do matter!



Slide 19

Cultural Competence
Integrating Differences
into Community Services

Objectives
Understand Stigma.
 Understand Culture Competency.
 Learn Culturally competent care for
people with Mental Health, Mental
Retardation and Addictions.


We live in an world
which often separates us.
Racism
 Sexism
 Ageism
 Feminism
 Classism
 Atheism


“Different” people are
“Stigmatized”

Mentally retarded inmates in a sanitorium in Germany

Stigma
Definitions from the U. of Chicago PSR Training Manual

“Stigmas are negative attitudes about a
group that lead to depriving them of
some fair opportunities.”

Stigma is related to…..
Stereotypes
Prejudice
Discrimination

Stereotypes
from The Asian Health Coalition of Illinois

Stereotypes are exaggerated beliefs
or fixed ideas about a person or
group which is held by people and
sustained by selective perception and
selective forgetting.

Prejudice
from The Asian Health Coalition of Illinois

Prejudice is a preconceived idea or
negative attitude formed before the
facts are known and sustained over
generalizations. A bias without
reason, resisting all evidence…

Discrimination
from The Asian Health Coalition of Illinois

Discrimination refers to treatment in
favor or against a person based on
the group to which that person
belongs and not on merit.

Stigmatized People…..
Experience being stereotyped and
are often the object of
discrimination and prejudice.

People are often stigmatized by:













Mental Illness
Mental Retardation
Physical Disability (including blindness, deafness)
Alcoholism /and or Drug Addiction
HIV or AIDS, Cancer or other terminal illnesses
Criminal behavior
Poverty
Alternative Lifestyles/sexual orientation
Wheelchair bound
Gender
Obesity

All our Consumers belong to
stigmatized groups!

Stigmatized People
Consumers and their families
can’t navigate the bureaucracy
even if resources are there.
It’s too frustrating!

Use People First Language
“I am more than my
illness….Don’t call me
“the schizophrenic,
“the addict” or
“the retard.”

As human beings, we have many
similarities…..
But, who we really are, is often
derived from our original family of origin
and our current lifestyle.

The Bottom Line:
People are different, even within
their own culture!
These differences matter when
planning and providing services.

National Mental Health
Association
“For Mental Health consumers, both
access to the services and the effectiveness
of the care they receive are greatly affected
by the degree to which the delivery system
is“culturally competent.”

Some important definitions
Related to Cultural Competency

Culture

from King,et. al

The Office of Special Programs, U.S. Dept. of Education

“The integrated patterns of human
behavior that includes thoughts,
communications, actions, customs,
beliefs,values, and institutions of
racial, ethnic, religious, or social
groups.”

Cultural Sensitivity
An awareness and respect of a
person’s cultural beliefs and
values.
Culhane-Pera, et .al

Cultural Competency
 Skills

(that translate into)
 Behaviors, Practices, Attitudes, and
 Policies
That enable an individual, agency, or
system to effectively serve culturally
diverse communities.
from The Asian Health Coalition of Illinois

Here at Hill Country MHDDC
Consumers are very diverse in their
language and culture.

61% of our Consumers are
Caucasian Americans
Many have German
backgrounds.

Our Consumers are …..

n
1% NativeAmerican

33% Hispanic
1% Asian

3% African
American

1% are “Others”

Consumers Have Many
Different Lifestyles

Lifestyles

They have many different
beliefs.

Can We Communicate?
Think Language first!
 Do we need an interpreter?
 Communicate respectfully.
 Be sensitive to the consumer and the family.
 Consider your dress, tone of voice, eye contact,
location, seating arrangement, privacy, etc.


Is our approach culturally
appropriate?
“What do you call your problem?”
“What name does it have?”
“What do you think caused your problem?”
“Why do you think it started when it did?”
From Arthur Kleinman’s question protocol in“Culture,Illness, and Care:
Clinical Lessons from Anthropologic and Cross Cultural Research”,
Ann.Intern.Med. 1978:Vol.88, pg.251-258

Important Issues to Consider…





Impact of religion.
How are women, men, elders, and children
treated in their culture?
Is there domestic violence?
Ethnic minorities generally underutilize
outpatient services, although African-Americans
are over-represented in inpatient setting.

Diagnosis






Minorities with Bipolar Disorder are often
diagnosed with schizophrenia. (Mukherjee,et al)
African Americans are over diagnosed with
schizophrenia and under diagnosed with mood
disorders. (Bell )
A mental health consumer’s addictions may not
be treated.
The elderly may not be assessed for substance
abuse or alcoholism.

Diagnosis
A person with a primary addiction problem
might not be treated for a co-occurring mental
illness.
 Learning disabilities may not be identified in
individuals with mental illness or substance
abuse.
 A person with mental retardation may not be
treated for mental illness or substance abuse.


Diagnosis
Post Traumatic Stress Disorder is often
undiagnosed in people suffering from
Domestic Abuse or other trauma.
 Children who are witnessing or are
victims of domestic abuse or another
trauma, may be misdiagnosed with
Attention Deficit Hyperactivity Disorder.


Medication Differences





Asians and Hispanics need lower doses of antipsychotics.
African Americans use the same doses of antipsychotics, but lower doses of lithium.
The elderly need lower dosages of medications.
Thus, metabolism of drugs varies with age and
ethnicity and is critical in prescribing
medications.

From “Making Room for Culture in Psychiatry” by Lin, et al.

Pain Tolerance
Men and women tolerate pain differently.
 Cultures tolerate pain differently.
 People with addictions develop a
hypersensitivity to pain.
 In certain cultures, self-inflicted pain is a
part of a religious experience.


Religion





Religious beliefs shape how the world is viewed.
Is illness a punishment? The devil’s work? An
evil spell? Bad karma?
For Hispanics, the curandero is a trusted healer.
For Lakota Sioux, the ritual Vision Quest,
praying and fasting at a holy site is life
changing.

Remember there are as many
differences
Between individuals in the same
culture as there are between
individuals in different cultures!

Two African American
families, one lesbian
and the other, multi-racial.

German Consumers
Suggestions from our Gillespie County MH staff

What generation German?
 Would they feel more comfortable
speaking in German?


A consumer reacting to internal stimuli.

German Consumers
Suggestions from our Gillespie MHC staff in Fredericksburg

They may be resistant to seeking
mental services.
They may be reluctant to take medication.
They may “keep things within the family.”
They are concerned about the stigma.

German Consumers
They may feel it’s a character flaw or a
disgrace.
 They are very concerned about
confidentiality.
 Drinking alcohol is an accepted part of
their culture.
 Teen drinking may be acceptable in their
family.


Hispanic Consumers
from the U.S. Census, 1/23/03 Houston Chronicle

Hispanics are the largest minority group in
the U.S. with 37 million people.
 Texas is approximately 32 percent
Hispanic
 11.5 % African American,
 3.3% Other
 53.1% Anglo


Treatment Issues for Hispanic
Consumers
Do we need an interpreter?
 Is the person Tejano or from Mexico?
What generation Hispanic?
Is the person using a curandero?

Treatment issues for Hispanic
Consumers
Hallucinations are natural in their
religion.
 Hearing the voice of a loved one or having
hallucinations might be an expectations
when celebrating the Day of the Dead.
 Hispanic families are patriarchal.


Hispanic Consumers and
The Day of the Dead
A man is dressed in a skeleton
costume to portray death
in a celebration of
Dia de los Muertos,
The Day of the Dead.
People visit the graves of their
dead relatives to honor them.

Native Americans

Treatment Issues for Native
American Consumers
 Impact of racism,unemployment,and poverty.
 Coping with reservation life and
assimilation in mainstream culture.
 Consider the obesity, diabetes,
hypertension, and alcoholism in adults
and fetal alcohol syndrome in children.
 High use of native healers in the Southwest.

African Americans

African Americans
from the Houston Chronicle, 1/23/03

There are 36.2 million Americans who
identify themselves as “black only.”
 37.7 million identify themselves as “black
and at least one other race.”
 11.5% of Texans are African Americans.


Treatment Issues for African
American
Assess for co-occurring substance use
disorders and alcoholism.
 Address complications of obesity,
hypertension, diabetes,congestive heart
failure, asthma, and cancer.
 Sickle cell anemia is another illness
specific to African Americans.


Treatment Issues for African
Americans
Matriarchy; Mom or grandmother are the
dominant family figures.
 Lack of male role models and intact
families.
 Extended family or the Church may be
supports.


Treatment Issues for African
Americans


There is discrimination within their own
group based on skin color, hair texture,
class, values, etc.

Treatment Issues for Asians

Asians rarely seek help until its very severe.
Asians have extremely low admissions to state hospitals.
Mental illness is considered shameful. It’s hidden.
Is an interpreter needed?

Treatment Issues for Asians
Focus on physical symptoms.
 Asians are sensitive to medication.
 Give ½ the standard dose.
 Asians may use traditional healers and
herbal medicine.
 Asians may “flush” when drinking
alcohol.


Asian Consumers

Acupuncture has been used to treat
pain, schizophrenia, depression, and addictions.

Treatment Issues for Asians
Asian Cultures are patriarchal.
 The males in the family have the authority.
 Asians are more formal and inhibited in
their social behavior.


Older Adults

Treatment Issues for Older
Adults
Are they aware they need help?

Treatment Issues for Older
Adults
Is their mental illness caused by medicine?
 Do their medical problems cause or
complicate their mental illness?
 Is there Elder Abuse?


Gay Men and Lesbian Women
May struggle with homophobia and“being in the
closet” at work and with their families.
Gay people may want marriage, children, partner
benefits, etc., but may endure legal barriers.

Gay and Lesbian Women
Gay people often have specific health
issues related to their sexual practices.
 HIV, AIDS and STD’s are still concerns
with Gay men.
 People may be grieving the death of a
partner or friends who’ve died from AIDS,
or coping with living with AIDS or being
HIV+ themselves.


Treatment Issues for Gay and
Lesbians
Explore childhood abuse issues and
Domestic Violence..
 Assess for substance use and alcoholism.
 Sex enhancing drug use may be common
among some gay men.


Physically Challenged
Can they get to treatment?
Deal with their frustration and depression
Re: their disability.
 Do they need vocational assistance?

Mentally Challenged

Treatment Issues of Mentally
Challenged
They need to have meaningful activity
and purpose in their lives.
 They need to feel acknowledged and
appreciated.
 They need safety, structure, and security.
 Lack of continuity can cause crisis!
 They may need vocational assistance.


Winona Ryder

December 12, 2001,
Winona Ryder shoplifted
$5,560.40 designer items
from Saks Fifth Avenue in
Beverley Hills.

Twice an Academy
Award Nominated
actress

She had the following 8 drugs in
her possession:
Liquid demerol
 Liquid Diazepam
 Vicodin
 Percodan
 Valium
 Morphine sulfate
 Endocet (containing Oxycodone)


Patterns of Drug Use are highly
Regional.
 Drugs,

routes of administration, street
names, patterns of use, and drug
combinations may differ greatly, not
only between individuals from
different cultures, but different parts
of the country or even different parts
of the city.

Drugs of Choice
Native Americans-alcohol
 Asians-gambling, work
 Gay Men-stimulants, amyl nitrate, ecstasy
 “Rich”-prescription drugs, Internet porn
 M.D.’s –Vicodin


Drugs of Choice
Young adults-marijuana, cigarettes
 Geriatrics-alcohol, pills
 Sex Workers-crack cocaine, IV speedballs
 Screen mentally retarded for abuse too!


How Do We Best Serve Our
Consumers?




Examine own stereotypes.
Build trust.
Use People First language!

How do we best serve our
consumers?
Pronounce the person’s name correctly.
 Get an interpreter, if necessary.
 Educate yourself from the consumer, his
family, co-workers, etc.
 Remember differences do matter!



Slide 20

Cultural Competence
Integrating Differences
into Community Services

Objectives
Understand Stigma.
 Understand Culture Competency.
 Learn Culturally competent care for
people with Mental Health, Mental
Retardation and Addictions.


We live in an world
which often separates us.
Racism
 Sexism
 Ageism
 Feminism
 Classism
 Atheism


“Different” people are
“Stigmatized”

Mentally retarded inmates in a sanitorium in Germany

Stigma
Definitions from the U. of Chicago PSR Training Manual

“Stigmas are negative attitudes about a
group that lead to depriving them of
some fair opportunities.”

Stigma is related to…..
Stereotypes
Prejudice
Discrimination

Stereotypes
from The Asian Health Coalition of Illinois

Stereotypes are exaggerated beliefs
or fixed ideas about a person or
group which is held by people and
sustained by selective perception and
selective forgetting.

Prejudice
from The Asian Health Coalition of Illinois

Prejudice is a preconceived idea or
negative attitude formed before the
facts are known and sustained over
generalizations. A bias without
reason, resisting all evidence…

Discrimination
from The Asian Health Coalition of Illinois

Discrimination refers to treatment in
favor or against a person based on
the group to which that person
belongs and not on merit.

Stigmatized People…..
Experience being stereotyped and
are often the object of
discrimination and prejudice.

People are often stigmatized by:













Mental Illness
Mental Retardation
Physical Disability (including blindness, deafness)
Alcoholism /and or Drug Addiction
HIV or AIDS, Cancer or other terminal illnesses
Criminal behavior
Poverty
Alternative Lifestyles/sexual orientation
Wheelchair bound
Gender
Obesity

All our Consumers belong to
stigmatized groups!

Stigmatized People
Consumers and their families
can’t navigate the bureaucracy
even if resources are there.
It’s too frustrating!

Use People First Language
“I am more than my
illness….Don’t call me
“the schizophrenic,
“the addict” or
“the retard.”

As human beings, we have many
similarities…..
But, who we really are, is often
derived from our original family of origin
and our current lifestyle.

The Bottom Line:
People are different, even within
their own culture!
These differences matter when
planning and providing services.

National Mental Health
Association
“For Mental Health consumers, both
access to the services and the effectiveness
of the care they receive are greatly affected
by the degree to which the delivery system
is“culturally competent.”

Some important definitions
Related to Cultural Competency

Culture

from King,et. al

The Office of Special Programs, U.S. Dept. of Education

“The integrated patterns of human
behavior that includes thoughts,
communications, actions, customs,
beliefs,values, and institutions of
racial, ethnic, religious, or social
groups.”

Cultural Sensitivity
An awareness and respect of a
person’s cultural beliefs and
values.
Culhane-Pera, et .al

Cultural Competency
 Skills

(that translate into)
 Behaviors, Practices, Attitudes, and
 Policies
That enable an individual, agency, or
system to effectively serve culturally
diverse communities.
from The Asian Health Coalition of Illinois

Here at Hill Country MHDDC
Consumers are very diverse in their
language and culture.

61% of our Consumers are
Caucasian Americans
Many have German
backgrounds.

Our Consumers are …..

n
1% NativeAmerican

33% Hispanic
1% Asian

3% African
American

1% are “Others”

Consumers Have Many
Different Lifestyles

Lifestyles

They have many different
beliefs.

Can We Communicate?
Think Language first!
 Do we need an interpreter?
 Communicate respectfully.
 Be sensitive to the consumer and the family.
 Consider your dress, tone of voice, eye contact,
location, seating arrangement, privacy, etc.


Is our approach culturally
appropriate?
“What do you call your problem?”
“What name does it have?”
“What do you think caused your problem?”
“Why do you think it started when it did?”
From Arthur Kleinman’s question protocol in“Culture,Illness, and Care:
Clinical Lessons from Anthropologic and Cross Cultural Research”,
Ann.Intern.Med. 1978:Vol.88, pg.251-258

Important Issues to Consider…





Impact of religion.
How are women, men, elders, and children
treated in their culture?
Is there domestic violence?
Ethnic minorities generally underutilize
outpatient services, although African-Americans
are over-represented in inpatient setting.

Diagnosis






Minorities with Bipolar Disorder are often
diagnosed with schizophrenia. (Mukherjee,et al)
African Americans are over diagnosed with
schizophrenia and under diagnosed with mood
disorders. (Bell )
A mental health consumer’s addictions may not
be treated.
The elderly may not be assessed for substance
abuse or alcoholism.

Diagnosis
A person with a primary addiction problem
might not be treated for a co-occurring mental
illness.
 Learning disabilities may not be identified in
individuals with mental illness or substance
abuse.
 A person with mental retardation may not be
treated for mental illness or substance abuse.


Diagnosis
Post Traumatic Stress Disorder is often
undiagnosed in people suffering from
Domestic Abuse or other trauma.
 Children who are witnessing or are
victims of domestic abuse or another
trauma, may be misdiagnosed with
Attention Deficit Hyperactivity Disorder.


Medication Differences





Asians and Hispanics need lower doses of antipsychotics.
African Americans use the same doses of antipsychotics, but lower doses of lithium.
The elderly need lower dosages of medications.
Thus, metabolism of drugs varies with age and
ethnicity and is critical in prescribing
medications.

From “Making Room for Culture in Psychiatry” by Lin, et al.

Pain Tolerance
Men and women tolerate pain differently.
 Cultures tolerate pain differently.
 People with addictions develop a
hypersensitivity to pain.
 In certain cultures, self-inflicted pain is a
part of a religious experience.


Religion





Religious beliefs shape how the world is viewed.
Is illness a punishment? The devil’s work? An
evil spell? Bad karma?
For Hispanics, the curandero is a trusted healer.
For Lakota Sioux, the ritual Vision Quest,
praying and fasting at a holy site is life
changing.

Remember there are as many
differences
Between individuals in the same
culture as there are between
individuals in different cultures!

Two African American
families, one lesbian
and the other, multi-racial.

German Consumers
Suggestions from our Gillespie County MH staff

What generation German?
 Would they feel more comfortable
speaking in German?


A consumer reacting to internal stimuli.

German Consumers
Suggestions from our Gillespie MHC staff in Fredericksburg

They may be resistant to seeking
mental services.
They may be reluctant to take medication.
They may “keep things within the family.”
They are concerned about the stigma.

German Consumers
They may feel it’s a character flaw or a
disgrace.
 They are very concerned about
confidentiality.
 Drinking alcohol is an accepted part of
their culture.
 Teen drinking may be acceptable in their
family.


Hispanic Consumers
from the U.S. Census, 1/23/03 Houston Chronicle

Hispanics are the largest minority group in
the U.S. with 37 million people.
 Texas is approximately 32 percent
Hispanic
 11.5 % African American,
 3.3% Other
 53.1% Anglo


Treatment Issues for Hispanic
Consumers
Do we need an interpreter?
 Is the person Tejano or from Mexico?
What generation Hispanic?
Is the person using a curandero?

Treatment issues for Hispanic
Consumers
Hallucinations are natural in their
religion.
 Hearing the voice of a loved one or having
hallucinations might be an expectations
when celebrating the Day of the Dead.
 Hispanic families are patriarchal.


Hispanic Consumers and
The Day of the Dead
A man is dressed in a skeleton
costume to portray death
in a celebration of
Dia de los Muertos,
The Day of the Dead.
People visit the graves of their
dead relatives to honor them.

Native Americans

Treatment Issues for Native
American Consumers
 Impact of racism,unemployment,and poverty.
 Coping with reservation life and
assimilation in mainstream culture.
 Consider the obesity, diabetes,
hypertension, and alcoholism in adults
and fetal alcohol syndrome in children.
 High use of native healers in the Southwest.

African Americans

African Americans
from the Houston Chronicle, 1/23/03

There are 36.2 million Americans who
identify themselves as “black only.”
 37.7 million identify themselves as “black
and at least one other race.”
 11.5% of Texans are African Americans.


Treatment Issues for African
American
Assess for co-occurring substance use
disorders and alcoholism.
 Address complications of obesity,
hypertension, diabetes,congestive heart
failure, asthma, and cancer.
 Sickle cell anemia is another illness
specific to African Americans.


Treatment Issues for African
Americans
Matriarchy; Mom or grandmother are the
dominant family figures.
 Lack of male role models and intact
families.
 Extended family or the Church may be
supports.


Treatment Issues for African
Americans


There is discrimination within their own
group based on skin color, hair texture,
class, values, etc.

Treatment Issues for Asians

Asians rarely seek help until its very severe.
Asians have extremely low admissions to state hospitals.
Mental illness is considered shameful. It’s hidden.
Is an interpreter needed?

Treatment Issues for Asians
Focus on physical symptoms.
 Asians are sensitive to medication.
 Give ½ the standard dose.
 Asians may use traditional healers and
herbal medicine.
 Asians may “flush” when drinking
alcohol.


Asian Consumers

Acupuncture has been used to treat
pain, schizophrenia, depression, and addictions.

Treatment Issues for Asians
Asian Cultures are patriarchal.
 The males in the family have the authority.
 Asians are more formal and inhibited in
their social behavior.


Older Adults

Treatment Issues for Older
Adults
Are they aware they need help?

Treatment Issues for Older
Adults
Is their mental illness caused by medicine?
 Do their medical problems cause or
complicate their mental illness?
 Is there Elder Abuse?


Gay Men and Lesbian Women
May struggle with homophobia and“being in the
closet” at work and with their families.
Gay people may want marriage, children, partner
benefits, etc., but may endure legal barriers.

Gay and Lesbian Women
Gay people often have specific health
issues related to their sexual practices.
 HIV, AIDS and STD’s are still concerns
with Gay men.
 People may be grieving the death of a
partner or friends who’ve died from AIDS,
or coping with living with AIDS or being
HIV+ themselves.


Treatment Issues for Gay and
Lesbians
Explore childhood abuse issues and
Domestic Violence..
 Assess for substance use and alcoholism.
 Sex enhancing drug use may be common
among some gay men.


Physically Challenged
Can they get to treatment?
Deal with their frustration and depression
Re: their disability.
 Do they need vocational assistance?

Mentally Challenged

Treatment Issues of Mentally
Challenged
They need to have meaningful activity
and purpose in their lives.
 They need to feel acknowledged and
appreciated.
 They need safety, structure, and security.
 Lack of continuity can cause crisis!
 They may need vocational assistance.


Winona Ryder

December 12, 2001,
Winona Ryder shoplifted
$5,560.40 designer items
from Saks Fifth Avenue in
Beverley Hills.

Twice an Academy
Award Nominated
actress

She had the following 8 drugs in
her possession:
Liquid demerol
 Liquid Diazepam
 Vicodin
 Percodan
 Valium
 Morphine sulfate
 Endocet (containing Oxycodone)


Patterns of Drug Use are highly
Regional.
 Drugs,

routes of administration, street
names, patterns of use, and drug
combinations may differ greatly, not
only between individuals from
different cultures, but different parts
of the country or even different parts
of the city.

Drugs of Choice
Native Americans-alcohol
 Asians-gambling, work
 Gay Men-stimulants, amyl nitrate, ecstasy
 “Rich”-prescription drugs, Internet porn
 M.D.’s –Vicodin


Drugs of Choice
Young adults-marijuana, cigarettes
 Geriatrics-alcohol, pills
 Sex Workers-crack cocaine, IV speedballs
 Screen mentally retarded for abuse too!


How Do We Best Serve Our
Consumers?




Examine own stereotypes.
Build trust.
Use People First language!

How do we best serve our
consumers?
Pronounce the person’s name correctly.
 Get an interpreter, if necessary.
 Educate yourself from the consumer, his
family, co-workers, etc.
 Remember differences do matter!



Slide 21

Cultural Competence
Integrating Differences
into Community Services

Objectives
Understand Stigma.
 Understand Culture Competency.
 Learn Culturally competent care for
people with Mental Health, Mental
Retardation and Addictions.


We live in an world
which often separates us.
Racism
 Sexism
 Ageism
 Feminism
 Classism
 Atheism


“Different” people are
“Stigmatized”

Mentally retarded inmates in a sanitorium in Germany

Stigma
Definitions from the U. of Chicago PSR Training Manual

“Stigmas are negative attitudes about a
group that lead to depriving them of
some fair opportunities.”

Stigma is related to…..
Stereotypes
Prejudice
Discrimination

Stereotypes
from The Asian Health Coalition of Illinois

Stereotypes are exaggerated beliefs
or fixed ideas about a person or
group which is held by people and
sustained by selective perception and
selective forgetting.

Prejudice
from The Asian Health Coalition of Illinois

Prejudice is a preconceived idea or
negative attitude formed before the
facts are known and sustained over
generalizations. A bias without
reason, resisting all evidence…

Discrimination
from The Asian Health Coalition of Illinois

Discrimination refers to treatment in
favor or against a person based on
the group to which that person
belongs and not on merit.

Stigmatized People…..
Experience being stereotyped and
are often the object of
discrimination and prejudice.

People are often stigmatized by:













Mental Illness
Mental Retardation
Physical Disability (including blindness, deafness)
Alcoholism /and or Drug Addiction
HIV or AIDS, Cancer or other terminal illnesses
Criminal behavior
Poverty
Alternative Lifestyles/sexual orientation
Wheelchair bound
Gender
Obesity

All our Consumers belong to
stigmatized groups!

Stigmatized People
Consumers and their families
can’t navigate the bureaucracy
even if resources are there.
It’s too frustrating!

Use People First Language
“I am more than my
illness….Don’t call me
“the schizophrenic,
“the addict” or
“the retard.”

As human beings, we have many
similarities…..
But, who we really are, is often
derived from our original family of origin
and our current lifestyle.

The Bottom Line:
People are different, even within
their own culture!
These differences matter when
planning and providing services.

National Mental Health
Association
“For Mental Health consumers, both
access to the services and the effectiveness
of the care they receive are greatly affected
by the degree to which the delivery system
is“culturally competent.”

Some important definitions
Related to Cultural Competency

Culture

from King,et. al

The Office of Special Programs, U.S. Dept. of Education

“The integrated patterns of human
behavior that includes thoughts,
communications, actions, customs,
beliefs,values, and institutions of
racial, ethnic, religious, or social
groups.”

Cultural Sensitivity
An awareness and respect of a
person’s cultural beliefs and
values.
Culhane-Pera, et .al

Cultural Competency
 Skills

(that translate into)
 Behaviors, Practices, Attitudes, and
 Policies
That enable an individual, agency, or
system to effectively serve culturally
diverse communities.
from The Asian Health Coalition of Illinois

Here at Hill Country MHDDC
Consumers are very diverse in their
language and culture.

61% of our Consumers are
Caucasian Americans
Many have German
backgrounds.

Our Consumers are …..

n
1% NativeAmerican

33% Hispanic
1% Asian

3% African
American

1% are “Others”

Consumers Have Many
Different Lifestyles

Lifestyles

They have many different
beliefs.

Can We Communicate?
Think Language first!
 Do we need an interpreter?
 Communicate respectfully.
 Be sensitive to the consumer and the family.
 Consider your dress, tone of voice, eye contact,
location, seating arrangement, privacy, etc.


Is our approach culturally
appropriate?
“What do you call your problem?”
“What name does it have?”
“What do you think caused your problem?”
“Why do you think it started when it did?”
From Arthur Kleinman’s question protocol in“Culture,Illness, and Care:
Clinical Lessons from Anthropologic and Cross Cultural Research”,
Ann.Intern.Med. 1978:Vol.88, pg.251-258

Important Issues to Consider…





Impact of religion.
How are women, men, elders, and children
treated in their culture?
Is there domestic violence?
Ethnic minorities generally underutilize
outpatient services, although African-Americans
are over-represented in inpatient setting.

Diagnosis






Minorities with Bipolar Disorder are often
diagnosed with schizophrenia. (Mukherjee,et al)
African Americans are over diagnosed with
schizophrenia and under diagnosed with mood
disorders. (Bell )
A mental health consumer’s addictions may not
be treated.
The elderly may not be assessed for substance
abuse or alcoholism.

Diagnosis
A person with a primary addiction problem
might not be treated for a co-occurring mental
illness.
 Learning disabilities may not be identified in
individuals with mental illness or substance
abuse.
 A person with mental retardation may not be
treated for mental illness or substance abuse.


Diagnosis
Post Traumatic Stress Disorder is often
undiagnosed in people suffering from
Domestic Abuse or other trauma.
 Children who are witnessing or are
victims of domestic abuse or another
trauma, may be misdiagnosed with
Attention Deficit Hyperactivity Disorder.


Medication Differences





Asians and Hispanics need lower doses of antipsychotics.
African Americans use the same doses of antipsychotics, but lower doses of lithium.
The elderly need lower dosages of medications.
Thus, metabolism of drugs varies with age and
ethnicity and is critical in prescribing
medications.

From “Making Room for Culture in Psychiatry” by Lin, et al.

Pain Tolerance
Men and women tolerate pain differently.
 Cultures tolerate pain differently.
 People with addictions develop a
hypersensitivity to pain.
 In certain cultures, self-inflicted pain is a
part of a religious experience.


Religion





Religious beliefs shape how the world is viewed.
Is illness a punishment? The devil’s work? An
evil spell? Bad karma?
For Hispanics, the curandero is a trusted healer.
For Lakota Sioux, the ritual Vision Quest,
praying and fasting at a holy site is life
changing.

Remember there are as many
differences
Between individuals in the same
culture as there are between
individuals in different cultures!

Two African American
families, one lesbian
and the other, multi-racial.

German Consumers
Suggestions from our Gillespie County MH staff

What generation German?
 Would they feel more comfortable
speaking in German?


A consumer reacting to internal stimuli.

German Consumers
Suggestions from our Gillespie MHC staff in Fredericksburg

They may be resistant to seeking
mental services.
They may be reluctant to take medication.
They may “keep things within the family.”
They are concerned about the stigma.

German Consumers
They may feel it’s a character flaw or a
disgrace.
 They are very concerned about
confidentiality.
 Drinking alcohol is an accepted part of
their culture.
 Teen drinking may be acceptable in their
family.


Hispanic Consumers
from the U.S. Census, 1/23/03 Houston Chronicle

Hispanics are the largest minority group in
the U.S. with 37 million people.
 Texas is approximately 32 percent
Hispanic
 11.5 % African American,
 3.3% Other
 53.1% Anglo


Treatment Issues for Hispanic
Consumers
Do we need an interpreter?
 Is the person Tejano or from Mexico?
What generation Hispanic?
Is the person using a curandero?

Treatment issues for Hispanic
Consumers
Hallucinations are natural in their
religion.
 Hearing the voice of a loved one or having
hallucinations might be an expectations
when celebrating the Day of the Dead.
 Hispanic families are patriarchal.


Hispanic Consumers and
The Day of the Dead
A man is dressed in a skeleton
costume to portray death
in a celebration of
Dia de los Muertos,
The Day of the Dead.
People visit the graves of their
dead relatives to honor them.

Native Americans

Treatment Issues for Native
American Consumers
 Impact of racism,unemployment,and poverty.
 Coping with reservation life and
assimilation in mainstream culture.
 Consider the obesity, diabetes,
hypertension, and alcoholism in adults
and fetal alcohol syndrome in children.
 High use of native healers in the Southwest.

African Americans

African Americans
from the Houston Chronicle, 1/23/03

There are 36.2 million Americans who
identify themselves as “black only.”
 37.7 million identify themselves as “black
and at least one other race.”
 11.5% of Texans are African Americans.


Treatment Issues for African
American
Assess for co-occurring substance use
disorders and alcoholism.
 Address complications of obesity,
hypertension, diabetes,congestive heart
failure, asthma, and cancer.
 Sickle cell anemia is another illness
specific to African Americans.


Treatment Issues for African
Americans
Matriarchy; Mom or grandmother are the
dominant family figures.
 Lack of male role models and intact
families.
 Extended family or the Church may be
supports.


Treatment Issues for African
Americans


There is discrimination within their own
group based on skin color, hair texture,
class, values, etc.

Treatment Issues for Asians

Asians rarely seek help until its very severe.
Asians have extremely low admissions to state hospitals.
Mental illness is considered shameful. It’s hidden.
Is an interpreter needed?

Treatment Issues for Asians
Focus on physical symptoms.
 Asians are sensitive to medication.
 Give ½ the standard dose.
 Asians may use traditional healers and
herbal medicine.
 Asians may “flush” when drinking
alcohol.


Asian Consumers

Acupuncture has been used to treat
pain, schizophrenia, depression, and addictions.

Treatment Issues for Asians
Asian Cultures are patriarchal.
 The males in the family have the authority.
 Asians are more formal and inhibited in
their social behavior.


Older Adults

Treatment Issues for Older
Adults
Are they aware they need help?

Treatment Issues for Older
Adults
Is their mental illness caused by medicine?
 Do their medical problems cause or
complicate their mental illness?
 Is there Elder Abuse?


Gay Men and Lesbian Women
May struggle with homophobia and“being in the
closet” at work and with their families.
Gay people may want marriage, children, partner
benefits, etc., but may endure legal barriers.

Gay and Lesbian Women
Gay people often have specific health
issues related to their sexual practices.
 HIV, AIDS and STD’s are still concerns
with Gay men.
 People may be grieving the death of a
partner or friends who’ve died from AIDS,
or coping with living with AIDS or being
HIV+ themselves.


Treatment Issues for Gay and
Lesbians
Explore childhood abuse issues and
Domestic Violence..
 Assess for substance use and alcoholism.
 Sex enhancing drug use may be common
among some gay men.


Physically Challenged
Can they get to treatment?
Deal with their frustration and depression
Re: their disability.
 Do they need vocational assistance?

Mentally Challenged

Treatment Issues of Mentally
Challenged
They need to have meaningful activity
and purpose in their lives.
 They need to feel acknowledged and
appreciated.
 They need safety, structure, and security.
 Lack of continuity can cause crisis!
 They may need vocational assistance.


Winona Ryder

December 12, 2001,
Winona Ryder shoplifted
$5,560.40 designer items
from Saks Fifth Avenue in
Beverley Hills.

Twice an Academy
Award Nominated
actress

She had the following 8 drugs in
her possession:
Liquid demerol
 Liquid Diazepam
 Vicodin
 Percodan
 Valium
 Morphine sulfate
 Endocet (containing Oxycodone)


Patterns of Drug Use are highly
Regional.
 Drugs,

routes of administration, street
names, patterns of use, and drug
combinations may differ greatly, not
only between individuals from
different cultures, but different parts
of the country or even different parts
of the city.

Drugs of Choice
Native Americans-alcohol
 Asians-gambling, work
 Gay Men-stimulants, amyl nitrate, ecstasy
 “Rich”-prescription drugs, Internet porn
 M.D.’s –Vicodin


Drugs of Choice
Young adults-marijuana, cigarettes
 Geriatrics-alcohol, pills
 Sex Workers-crack cocaine, IV speedballs
 Screen mentally retarded for abuse too!


How Do We Best Serve Our
Consumers?




Examine own stereotypes.
Build trust.
Use People First language!

How do we best serve our
consumers?
Pronounce the person’s name correctly.
 Get an interpreter, if necessary.
 Educate yourself from the consumer, his
family, co-workers, etc.
 Remember differences do matter!



Slide 22

Cultural Competence
Integrating Differences
into Community Services

Objectives
Understand Stigma.
 Understand Culture Competency.
 Learn Culturally competent care for
people with Mental Health, Mental
Retardation and Addictions.


We live in an world
which often separates us.
Racism
 Sexism
 Ageism
 Feminism
 Classism
 Atheism


“Different” people are
“Stigmatized”

Mentally retarded inmates in a sanitorium in Germany

Stigma
Definitions from the U. of Chicago PSR Training Manual

“Stigmas are negative attitudes about a
group that lead to depriving them of
some fair opportunities.”

Stigma is related to…..
Stereotypes
Prejudice
Discrimination

Stereotypes
from The Asian Health Coalition of Illinois

Stereotypes are exaggerated beliefs
or fixed ideas about a person or
group which is held by people and
sustained by selective perception and
selective forgetting.

Prejudice
from The Asian Health Coalition of Illinois

Prejudice is a preconceived idea or
negative attitude formed before the
facts are known and sustained over
generalizations. A bias without
reason, resisting all evidence…

Discrimination
from The Asian Health Coalition of Illinois

Discrimination refers to treatment in
favor or against a person based on
the group to which that person
belongs and not on merit.

Stigmatized People…..
Experience being stereotyped and
are often the object of
discrimination and prejudice.

People are often stigmatized by:













Mental Illness
Mental Retardation
Physical Disability (including blindness, deafness)
Alcoholism /and or Drug Addiction
HIV or AIDS, Cancer or other terminal illnesses
Criminal behavior
Poverty
Alternative Lifestyles/sexual orientation
Wheelchair bound
Gender
Obesity

All our Consumers belong to
stigmatized groups!

Stigmatized People
Consumers and their families
can’t navigate the bureaucracy
even if resources are there.
It’s too frustrating!

Use People First Language
“I am more than my
illness….Don’t call me
“the schizophrenic,
“the addict” or
“the retard.”

As human beings, we have many
similarities…..
But, who we really are, is often
derived from our original family of origin
and our current lifestyle.

The Bottom Line:
People are different, even within
their own culture!
These differences matter when
planning and providing services.

National Mental Health
Association
“For Mental Health consumers, both
access to the services and the effectiveness
of the care they receive are greatly affected
by the degree to which the delivery system
is“culturally competent.”

Some important definitions
Related to Cultural Competency

Culture

from King,et. al

The Office of Special Programs, U.S. Dept. of Education

“The integrated patterns of human
behavior that includes thoughts,
communications, actions, customs,
beliefs,values, and institutions of
racial, ethnic, religious, or social
groups.”

Cultural Sensitivity
An awareness and respect of a
person’s cultural beliefs and
values.
Culhane-Pera, et .al

Cultural Competency
 Skills

(that translate into)
 Behaviors, Practices, Attitudes, and
 Policies
That enable an individual, agency, or
system to effectively serve culturally
diverse communities.
from The Asian Health Coalition of Illinois

Here at Hill Country MHDDC
Consumers are very diverse in their
language and culture.

61% of our Consumers are
Caucasian Americans
Many have German
backgrounds.

Our Consumers are …..

n
1% NativeAmerican

33% Hispanic
1% Asian

3% African
American

1% are “Others”

Consumers Have Many
Different Lifestyles

Lifestyles

They have many different
beliefs.

Can We Communicate?
Think Language first!
 Do we need an interpreter?
 Communicate respectfully.
 Be sensitive to the consumer and the family.
 Consider your dress, tone of voice, eye contact,
location, seating arrangement, privacy, etc.


Is our approach culturally
appropriate?
“What do you call your problem?”
“What name does it have?”
“What do you think caused your problem?”
“Why do you think it started when it did?”
From Arthur Kleinman’s question protocol in“Culture,Illness, and Care:
Clinical Lessons from Anthropologic and Cross Cultural Research”,
Ann.Intern.Med. 1978:Vol.88, pg.251-258

Important Issues to Consider…





Impact of religion.
How are women, men, elders, and children
treated in their culture?
Is there domestic violence?
Ethnic minorities generally underutilize
outpatient services, although African-Americans
are over-represented in inpatient setting.

Diagnosis






Minorities with Bipolar Disorder are often
diagnosed with schizophrenia. (Mukherjee,et al)
African Americans are over diagnosed with
schizophrenia and under diagnosed with mood
disorders. (Bell )
A mental health consumer’s addictions may not
be treated.
The elderly may not be assessed for substance
abuse or alcoholism.

Diagnosis
A person with a primary addiction problem
might not be treated for a co-occurring mental
illness.
 Learning disabilities may not be identified in
individuals with mental illness or substance
abuse.
 A person with mental retardation may not be
treated for mental illness or substance abuse.


Diagnosis
Post Traumatic Stress Disorder is often
undiagnosed in people suffering from
Domestic Abuse or other trauma.
 Children who are witnessing or are
victims of domestic abuse or another
trauma, may be misdiagnosed with
Attention Deficit Hyperactivity Disorder.


Medication Differences





Asians and Hispanics need lower doses of antipsychotics.
African Americans use the same doses of antipsychotics, but lower doses of lithium.
The elderly need lower dosages of medications.
Thus, metabolism of drugs varies with age and
ethnicity and is critical in prescribing
medications.

From “Making Room for Culture in Psychiatry” by Lin, et al.

Pain Tolerance
Men and women tolerate pain differently.
 Cultures tolerate pain differently.
 People with addictions develop a
hypersensitivity to pain.
 In certain cultures, self-inflicted pain is a
part of a religious experience.


Religion





Religious beliefs shape how the world is viewed.
Is illness a punishment? The devil’s work? An
evil spell? Bad karma?
For Hispanics, the curandero is a trusted healer.
For Lakota Sioux, the ritual Vision Quest,
praying and fasting at a holy site is life
changing.

Remember there are as many
differences
Between individuals in the same
culture as there are between
individuals in different cultures!

Two African American
families, one lesbian
and the other, multi-racial.

German Consumers
Suggestions from our Gillespie County MH staff

What generation German?
 Would they feel more comfortable
speaking in German?


A consumer reacting to internal stimuli.

German Consumers
Suggestions from our Gillespie MHC staff in Fredericksburg

They may be resistant to seeking
mental services.
They may be reluctant to take medication.
They may “keep things within the family.”
They are concerned about the stigma.

German Consumers
They may feel it’s a character flaw or a
disgrace.
 They are very concerned about
confidentiality.
 Drinking alcohol is an accepted part of
their culture.
 Teen drinking may be acceptable in their
family.


Hispanic Consumers
from the U.S. Census, 1/23/03 Houston Chronicle

Hispanics are the largest minority group in
the U.S. with 37 million people.
 Texas is approximately 32 percent
Hispanic
 11.5 % African American,
 3.3% Other
 53.1% Anglo


Treatment Issues for Hispanic
Consumers
Do we need an interpreter?
 Is the person Tejano or from Mexico?
What generation Hispanic?
Is the person using a curandero?

Treatment issues for Hispanic
Consumers
Hallucinations are natural in their
religion.
 Hearing the voice of a loved one or having
hallucinations might be an expectations
when celebrating the Day of the Dead.
 Hispanic families are patriarchal.


Hispanic Consumers and
The Day of the Dead
A man is dressed in a skeleton
costume to portray death
in a celebration of
Dia de los Muertos,
The Day of the Dead.
People visit the graves of their
dead relatives to honor them.

Native Americans

Treatment Issues for Native
American Consumers
 Impact of racism,unemployment,and poverty.
 Coping with reservation life and
assimilation in mainstream culture.
 Consider the obesity, diabetes,
hypertension, and alcoholism in adults
and fetal alcohol syndrome in children.
 High use of native healers in the Southwest.

African Americans

African Americans
from the Houston Chronicle, 1/23/03

There are 36.2 million Americans who
identify themselves as “black only.”
 37.7 million identify themselves as “black
and at least one other race.”
 11.5% of Texans are African Americans.


Treatment Issues for African
American
Assess for co-occurring substance use
disorders and alcoholism.
 Address complications of obesity,
hypertension, diabetes,congestive heart
failure, asthma, and cancer.
 Sickle cell anemia is another illness
specific to African Americans.


Treatment Issues for African
Americans
Matriarchy; Mom or grandmother are the
dominant family figures.
 Lack of male role models and intact
families.
 Extended family or the Church may be
supports.


Treatment Issues for African
Americans


There is discrimination within their own
group based on skin color, hair texture,
class, values, etc.

Treatment Issues for Asians

Asians rarely seek help until its very severe.
Asians have extremely low admissions to state hospitals.
Mental illness is considered shameful. It’s hidden.
Is an interpreter needed?

Treatment Issues for Asians
Focus on physical symptoms.
 Asians are sensitive to medication.
 Give ½ the standard dose.
 Asians may use traditional healers and
herbal medicine.
 Asians may “flush” when drinking
alcohol.


Asian Consumers

Acupuncture has been used to treat
pain, schizophrenia, depression, and addictions.

Treatment Issues for Asians
Asian Cultures are patriarchal.
 The males in the family have the authority.
 Asians are more formal and inhibited in
their social behavior.


Older Adults

Treatment Issues for Older
Adults
Are they aware they need help?

Treatment Issues for Older
Adults
Is their mental illness caused by medicine?
 Do their medical problems cause or
complicate their mental illness?
 Is there Elder Abuse?


Gay Men and Lesbian Women
May struggle with homophobia and“being in the
closet” at work and with their families.
Gay people may want marriage, children, partner
benefits, etc., but may endure legal barriers.

Gay and Lesbian Women
Gay people often have specific health
issues related to their sexual practices.
 HIV, AIDS and STD’s are still concerns
with Gay men.
 People may be grieving the death of a
partner or friends who’ve died from AIDS,
or coping with living with AIDS or being
HIV+ themselves.


Treatment Issues for Gay and
Lesbians
Explore childhood abuse issues and
Domestic Violence..
 Assess for substance use and alcoholism.
 Sex enhancing drug use may be common
among some gay men.


Physically Challenged
Can they get to treatment?
Deal with their frustration and depression
Re: their disability.
 Do they need vocational assistance?

Mentally Challenged

Treatment Issues of Mentally
Challenged
They need to have meaningful activity
and purpose in their lives.
 They need to feel acknowledged and
appreciated.
 They need safety, structure, and security.
 Lack of continuity can cause crisis!
 They may need vocational assistance.


Winona Ryder

December 12, 2001,
Winona Ryder shoplifted
$5,560.40 designer items
from Saks Fifth Avenue in
Beverley Hills.

Twice an Academy
Award Nominated
actress

She had the following 8 drugs in
her possession:
Liquid demerol
 Liquid Diazepam
 Vicodin
 Percodan
 Valium
 Morphine sulfate
 Endocet (containing Oxycodone)


Patterns of Drug Use are highly
Regional.
 Drugs,

routes of administration, street
names, patterns of use, and drug
combinations may differ greatly, not
only between individuals from
different cultures, but different parts
of the country or even different parts
of the city.

Drugs of Choice
Native Americans-alcohol
 Asians-gambling, work
 Gay Men-stimulants, amyl nitrate, ecstasy
 “Rich”-prescription drugs, Internet porn
 M.D.’s –Vicodin


Drugs of Choice
Young adults-marijuana, cigarettes
 Geriatrics-alcohol, pills
 Sex Workers-crack cocaine, IV speedballs
 Screen mentally retarded for abuse too!


How Do We Best Serve Our
Consumers?




Examine own stereotypes.
Build trust.
Use People First language!

How do we best serve our
consumers?
Pronounce the person’s name correctly.
 Get an interpreter, if necessary.
 Educate yourself from the consumer, his
family, co-workers, etc.
 Remember differences do matter!



Slide 23

Cultural Competence
Integrating Differences
into Community Services

Objectives
Understand Stigma.
 Understand Culture Competency.
 Learn Culturally competent care for
people with Mental Health, Mental
Retardation and Addictions.


We live in an world
which often separates us.
Racism
 Sexism
 Ageism
 Feminism
 Classism
 Atheism


“Different” people are
“Stigmatized”

Mentally retarded inmates in a sanitorium in Germany

Stigma
Definitions from the U. of Chicago PSR Training Manual

“Stigmas are negative attitudes about a
group that lead to depriving them of
some fair opportunities.”

Stigma is related to…..
Stereotypes
Prejudice
Discrimination

Stereotypes
from The Asian Health Coalition of Illinois

Stereotypes are exaggerated beliefs
or fixed ideas about a person or
group which is held by people and
sustained by selective perception and
selective forgetting.

Prejudice
from The Asian Health Coalition of Illinois

Prejudice is a preconceived idea or
negative attitude formed before the
facts are known and sustained over
generalizations. A bias without
reason, resisting all evidence…

Discrimination
from The Asian Health Coalition of Illinois

Discrimination refers to treatment in
favor or against a person based on
the group to which that person
belongs and not on merit.

Stigmatized People…..
Experience being stereotyped and
are often the object of
discrimination and prejudice.

People are often stigmatized by:













Mental Illness
Mental Retardation
Physical Disability (including blindness, deafness)
Alcoholism /and or Drug Addiction
HIV or AIDS, Cancer or other terminal illnesses
Criminal behavior
Poverty
Alternative Lifestyles/sexual orientation
Wheelchair bound
Gender
Obesity

All our Consumers belong to
stigmatized groups!

Stigmatized People
Consumers and their families
can’t navigate the bureaucracy
even if resources are there.
It’s too frustrating!

Use People First Language
“I am more than my
illness….Don’t call me
“the schizophrenic,
“the addict” or
“the retard.”

As human beings, we have many
similarities…..
But, who we really are, is often
derived from our original family of origin
and our current lifestyle.

The Bottom Line:
People are different, even within
their own culture!
These differences matter when
planning and providing services.

National Mental Health
Association
“For Mental Health consumers, both
access to the services and the effectiveness
of the care they receive are greatly affected
by the degree to which the delivery system
is“culturally competent.”

Some important definitions
Related to Cultural Competency

Culture

from King,et. al

The Office of Special Programs, U.S. Dept. of Education

“The integrated patterns of human
behavior that includes thoughts,
communications, actions, customs,
beliefs,values, and institutions of
racial, ethnic, religious, or social
groups.”

Cultural Sensitivity
An awareness and respect of a
person’s cultural beliefs and
values.
Culhane-Pera, et .al

Cultural Competency
 Skills

(that translate into)
 Behaviors, Practices, Attitudes, and
 Policies
That enable an individual, agency, or
system to effectively serve culturally
diverse communities.
from The Asian Health Coalition of Illinois

Here at Hill Country MHDDC
Consumers are very diverse in their
language and culture.

61% of our Consumers are
Caucasian Americans
Many have German
backgrounds.

Our Consumers are …..

n
1% NativeAmerican

33% Hispanic
1% Asian

3% African
American

1% are “Others”

Consumers Have Many
Different Lifestyles

Lifestyles

They have many different
beliefs.

Can We Communicate?
Think Language first!
 Do we need an interpreter?
 Communicate respectfully.
 Be sensitive to the consumer and the family.
 Consider your dress, tone of voice, eye contact,
location, seating arrangement, privacy, etc.


Is our approach culturally
appropriate?
“What do you call your problem?”
“What name does it have?”
“What do you think caused your problem?”
“Why do you think it started when it did?”
From Arthur Kleinman’s question protocol in“Culture,Illness, and Care:
Clinical Lessons from Anthropologic and Cross Cultural Research”,
Ann.Intern.Med. 1978:Vol.88, pg.251-258

Important Issues to Consider…





Impact of religion.
How are women, men, elders, and children
treated in their culture?
Is there domestic violence?
Ethnic minorities generally underutilize
outpatient services, although African-Americans
are over-represented in inpatient setting.

Diagnosis






Minorities with Bipolar Disorder are often
diagnosed with schizophrenia. (Mukherjee,et al)
African Americans are over diagnosed with
schizophrenia and under diagnosed with mood
disorders. (Bell )
A mental health consumer’s addictions may not
be treated.
The elderly may not be assessed for substance
abuse or alcoholism.

Diagnosis
A person with a primary addiction problem
might not be treated for a co-occurring mental
illness.
 Learning disabilities may not be identified in
individuals with mental illness or substance
abuse.
 A person with mental retardation may not be
treated for mental illness or substance abuse.


Diagnosis
Post Traumatic Stress Disorder is often
undiagnosed in people suffering from
Domestic Abuse or other trauma.
 Children who are witnessing or are
victims of domestic abuse or another
trauma, may be misdiagnosed with
Attention Deficit Hyperactivity Disorder.


Medication Differences





Asians and Hispanics need lower doses of antipsychotics.
African Americans use the same doses of antipsychotics, but lower doses of lithium.
The elderly need lower dosages of medications.
Thus, metabolism of drugs varies with age and
ethnicity and is critical in prescribing
medications.

From “Making Room for Culture in Psychiatry” by Lin, et al.

Pain Tolerance
Men and women tolerate pain differently.
 Cultures tolerate pain differently.
 People with addictions develop a
hypersensitivity to pain.
 In certain cultures, self-inflicted pain is a
part of a religious experience.


Religion





Religious beliefs shape how the world is viewed.
Is illness a punishment? The devil’s work? An
evil spell? Bad karma?
For Hispanics, the curandero is a trusted healer.
For Lakota Sioux, the ritual Vision Quest,
praying and fasting at a holy site is life
changing.

Remember there are as many
differences
Between individuals in the same
culture as there are between
individuals in different cultures!

Two African American
families, one lesbian
and the other, multi-racial.

German Consumers
Suggestions from our Gillespie County MH staff

What generation German?
 Would they feel more comfortable
speaking in German?


A consumer reacting to internal stimuli.

German Consumers
Suggestions from our Gillespie MHC staff in Fredericksburg

They may be resistant to seeking
mental services.
They may be reluctant to take medication.
They may “keep things within the family.”
They are concerned about the stigma.

German Consumers
They may feel it’s a character flaw or a
disgrace.
 They are very concerned about
confidentiality.
 Drinking alcohol is an accepted part of
their culture.
 Teen drinking may be acceptable in their
family.


Hispanic Consumers
from the U.S. Census, 1/23/03 Houston Chronicle

Hispanics are the largest minority group in
the U.S. with 37 million people.
 Texas is approximately 32 percent
Hispanic
 11.5 % African American,
 3.3% Other
 53.1% Anglo


Treatment Issues for Hispanic
Consumers
Do we need an interpreter?
 Is the person Tejano or from Mexico?
What generation Hispanic?
Is the person using a curandero?

Treatment issues for Hispanic
Consumers
Hallucinations are natural in their
religion.
 Hearing the voice of a loved one or having
hallucinations might be an expectations
when celebrating the Day of the Dead.
 Hispanic families are patriarchal.


Hispanic Consumers and
The Day of the Dead
A man is dressed in a skeleton
costume to portray death
in a celebration of
Dia de los Muertos,
The Day of the Dead.
People visit the graves of their
dead relatives to honor them.

Native Americans

Treatment Issues for Native
American Consumers
 Impact of racism,unemployment,and poverty.
 Coping with reservation life and
assimilation in mainstream culture.
 Consider the obesity, diabetes,
hypertension, and alcoholism in adults
and fetal alcohol syndrome in children.
 High use of native healers in the Southwest.

African Americans

African Americans
from the Houston Chronicle, 1/23/03

There are 36.2 million Americans who
identify themselves as “black only.”
 37.7 million identify themselves as “black
and at least one other race.”
 11.5% of Texans are African Americans.


Treatment Issues for African
American
Assess for co-occurring substance use
disorders and alcoholism.
 Address complications of obesity,
hypertension, diabetes,congestive heart
failure, asthma, and cancer.
 Sickle cell anemia is another illness
specific to African Americans.


Treatment Issues for African
Americans
Matriarchy; Mom or grandmother are the
dominant family figures.
 Lack of male role models and intact
families.
 Extended family or the Church may be
supports.


Treatment Issues for African
Americans


There is discrimination within their own
group based on skin color, hair texture,
class, values, etc.

Treatment Issues for Asians

Asians rarely seek help until its very severe.
Asians have extremely low admissions to state hospitals.
Mental illness is considered shameful. It’s hidden.
Is an interpreter needed?

Treatment Issues for Asians
Focus on physical symptoms.
 Asians are sensitive to medication.
 Give ½ the standard dose.
 Asians may use traditional healers and
herbal medicine.
 Asians may “flush” when drinking
alcohol.


Asian Consumers

Acupuncture has been used to treat
pain, schizophrenia, depression, and addictions.

Treatment Issues for Asians
Asian Cultures are patriarchal.
 The males in the family have the authority.
 Asians are more formal and inhibited in
their social behavior.


Older Adults

Treatment Issues for Older
Adults
Are they aware they need help?

Treatment Issues for Older
Adults
Is their mental illness caused by medicine?
 Do their medical problems cause or
complicate their mental illness?
 Is there Elder Abuse?


Gay Men and Lesbian Women
May struggle with homophobia and“being in the
closet” at work and with their families.
Gay people may want marriage, children, partner
benefits, etc., but may endure legal barriers.

Gay and Lesbian Women
Gay people often have specific health
issues related to their sexual practices.
 HIV, AIDS and STD’s are still concerns
with Gay men.
 People may be grieving the death of a
partner or friends who’ve died from AIDS,
or coping with living with AIDS or being
HIV+ themselves.


Treatment Issues for Gay and
Lesbians
Explore childhood abuse issues and
Domestic Violence..
 Assess for substance use and alcoholism.
 Sex enhancing drug use may be common
among some gay men.


Physically Challenged
Can they get to treatment?
Deal with their frustration and depression
Re: their disability.
 Do they need vocational assistance?

Mentally Challenged

Treatment Issues of Mentally
Challenged
They need to have meaningful activity
and purpose in their lives.
 They need to feel acknowledged and
appreciated.
 They need safety, structure, and security.
 Lack of continuity can cause crisis!
 They may need vocational assistance.


Winona Ryder

December 12, 2001,
Winona Ryder shoplifted
$5,560.40 designer items
from Saks Fifth Avenue in
Beverley Hills.

Twice an Academy
Award Nominated
actress

She had the following 8 drugs in
her possession:
Liquid demerol
 Liquid Diazepam
 Vicodin
 Percodan
 Valium
 Morphine sulfate
 Endocet (containing Oxycodone)


Patterns of Drug Use are highly
Regional.
 Drugs,

routes of administration, street
names, patterns of use, and drug
combinations may differ greatly, not
only between individuals from
different cultures, but different parts
of the country or even different parts
of the city.

Drugs of Choice
Native Americans-alcohol
 Asians-gambling, work
 Gay Men-stimulants, amyl nitrate, ecstasy
 “Rich”-prescription drugs, Internet porn
 M.D.’s –Vicodin


Drugs of Choice
Young adults-marijuana, cigarettes
 Geriatrics-alcohol, pills
 Sex Workers-crack cocaine, IV speedballs
 Screen mentally retarded for abuse too!


How Do We Best Serve Our
Consumers?




Examine own stereotypes.
Build trust.
Use People First language!

How do we best serve our
consumers?
Pronounce the person’s name correctly.
 Get an interpreter, if necessary.
 Educate yourself from the consumer, his
family, co-workers, etc.
 Remember differences do matter!



Slide 24

Cultural Competence
Integrating Differences
into Community Services

Objectives
Understand Stigma.
 Understand Culture Competency.
 Learn Culturally competent care for
people with Mental Health, Mental
Retardation and Addictions.


We live in an world
which often separates us.
Racism
 Sexism
 Ageism
 Feminism
 Classism
 Atheism


“Different” people are
“Stigmatized”

Mentally retarded inmates in a sanitorium in Germany

Stigma
Definitions from the U. of Chicago PSR Training Manual

“Stigmas are negative attitudes about a
group that lead to depriving them of
some fair opportunities.”

Stigma is related to…..
Stereotypes
Prejudice
Discrimination

Stereotypes
from The Asian Health Coalition of Illinois

Stereotypes are exaggerated beliefs
or fixed ideas about a person or
group which is held by people and
sustained by selective perception and
selective forgetting.

Prejudice
from The Asian Health Coalition of Illinois

Prejudice is a preconceived idea or
negative attitude formed before the
facts are known and sustained over
generalizations. A bias without
reason, resisting all evidence…

Discrimination
from The Asian Health Coalition of Illinois

Discrimination refers to treatment in
favor or against a person based on
the group to which that person
belongs and not on merit.

Stigmatized People…..
Experience being stereotyped and
are often the object of
discrimination and prejudice.

People are often stigmatized by:













Mental Illness
Mental Retardation
Physical Disability (including blindness, deafness)
Alcoholism /and or Drug Addiction
HIV or AIDS, Cancer or other terminal illnesses
Criminal behavior
Poverty
Alternative Lifestyles/sexual orientation
Wheelchair bound
Gender
Obesity

All our Consumers belong to
stigmatized groups!

Stigmatized People
Consumers and their families
can’t navigate the bureaucracy
even if resources are there.
It’s too frustrating!

Use People First Language
“I am more than my
illness….Don’t call me
“the schizophrenic,
“the addict” or
“the retard.”

As human beings, we have many
similarities…..
But, who we really are, is often
derived from our original family of origin
and our current lifestyle.

The Bottom Line:
People are different, even within
their own culture!
These differences matter when
planning and providing services.

National Mental Health
Association
“For Mental Health consumers, both
access to the services and the effectiveness
of the care they receive are greatly affected
by the degree to which the delivery system
is“culturally competent.”

Some important definitions
Related to Cultural Competency

Culture

from King,et. al

The Office of Special Programs, U.S. Dept. of Education

“The integrated patterns of human
behavior that includes thoughts,
communications, actions, customs,
beliefs,values, and institutions of
racial, ethnic, religious, or social
groups.”

Cultural Sensitivity
An awareness and respect of a
person’s cultural beliefs and
values.
Culhane-Pera, et .al

Cultural Competency
 Skills

(that translate into)
 Behaviors, Practices, Attitudes, and
 Policies
That enable an individual, agency, or
system to effectively serve culturally
diverse communities.
from The Asian Health Coalition of Illinois

Here at Hill Country MHDDC
Consumers are very diverse in their
language and culture.

61% of our Consumers are
Caucasian Americans
Many have German
backgrounds.

Our Consumers are …..

n
1% NativeAmerican

33% Hispanic
1% Asian

3% African
American

1% are “Others”

Consumers Have Many
Different Lifestyles

Lifestyles

They have many different
beliefs.

Can We Communicate?
Think Language first!
 Do we need an interpreter?
 Communicate respectfully.
 Be sensitive to the consumer and the family.
 Consider your dress, tone of voice, eye contact,
location, seating arrangement, privacy, etc.


Is our approach culturally
appropriate?
“What do you call your problem?”
“What name does it have?”
“What do you think caused your problem?”
“Why do you think it started when it did?”
From Arthur Kleinman’s question protocol in“Culture,Illness, and Care:
Clinical Lessons from Anthropologic and Cross Cultural Research”,
Ann.Intern.Med. 1978:Vol.88, pg.251-258

Important Issues to Consider…





Impact of religion.
How are women, men, elders, and children
treated in their culture?
Is there domestic violence?
Ethnic minorities generally underutilize
outpatient services, although African-Americans
are over-represented in inpatient setting.

Diagnosis






Minorities with Bipolar Disorder are often
diagnosed with schizophrenia. (Mukherjee,et al)
African Americans are over diagnosed with
schizophrenia and under diagnosed with mood
disorders. (Bell )
A mental health consumer’s addictions may not
be treated.
The elderly may not be assessed for substance
abuse or alcoholism.

Diagnosis
A person with a primary addiction problem
might not be treated for a co-occurring mental
illness.
 Learning disabilities may not be identified in
individuals with mental illness or substance
abuse.
 A person with mental retardation may not be
treated for mental illness or substance abuse.


Diagnosis
Post Traumatic Stress Disorder is often
undiagnosed in people suffering from
Domestic Abuse or other trauma.
 Children who are witnessing or are
victims of domestic abuse or another
trauma, may be misdiagnosed with
Attention Deficit Hyperactivity Disorder.


Medication Differences





Asians and Hispanics need lower doses of antipsychotics.
African Americans use the same doses of antipsychotics, but lower doses of lithium.
The elderly need lower dosages of medications.
Thus, metabolism of drugs varies with age and
ethnicity and is critical in prescribing
medications.

From “Making Room for Culture in Psychiatry” by Lin, et al.

Pain Tolerance
Men and women tolerate pain differently.
 Cultures tolerate pain differently.
 People with addictions develop a
hypersensitivity to pain.
 In certain cultures, self-inflicted pain is a
part of a religious experience.


Religion





Religious beliefs shape how the world is viewed.
Is illness a punishment? The devil’s work? An
evil spell? Bad karma?
For Hispanics, the curandero is a trusted healer.
For Lakota Sioux, the ritual Vision Quest,
praying and fasting at a holy site is life
changing.

Remember there are as many
differences
Between individuals in the same
culture as there are between
individuals in different cultures!

Two African American
families, one lesbian
and the other, multi-racial.

German Consumers
Suggestions from our Gillespie County MH staff

What generation German?
 Would they feel more comfortable
speaking in German?


A consumer reacting to internal stimuli.

German Consumers
Suggestions from our Gillespie MHC staff in Fredericksburg

They may be resistant to seeking
mental services.
They may be reluctant to take medication.
They may “keep things within the family.”
They are concerned about the stigma.

German Consumers
They may feel it’s a character flaw or a
disgrace.
 They are very concerned about
confidentiality.
 Drinking alcohol is an accepted part of
their culture.
 Teen drinking may be acceptable in their
family.


Hispanic Consumers
from the U.S. Census, 1/23/03 Houston Chronicle

Hispanics are the largest minority group in
the U.S. with 37 million people.
 Texas is approximately 32 percent
Hispanic
 11.5 % African American,
 3.3% Other
 53.1% Anglo


Treatment Issues for Hispanic
Consumers
Do we need an interpreter?
 Is the person Tejano or from Mexico?
What generation Hispanic?
Is the person using a curandero?

Treatment issues for Hispanic
Consumers
Hallucinations are natural in their
religion.
 Hearing the voice of a loved one or having
hallucinations might be an expectations
when celebrating the Day of the Dead.
 Hispanic families are patriarchal.


Hispanic Consumers and
The Day of the Dead
A man is dressed in a skeleton
costume to portray death
in a celebration of
Dia de los Muertos,
The Day of the Dead.
People visit the graves of their
dead relatives to honor them.

Native Americans

Treatment Issues for Native
American Consumers
 Impact of racism,unemployment,and poverty.
 Coping with reservation life and
assimilation in mainstream culture.
 Consider the obesity, diabetes,
hypertension, and alcoholism in adults
and fetal alcohol syndrome in children.
 High use of native healers in the Southwest.

African Americans

African Americans
from the Houston Chronicle, 1/23/03

There are 36.2 million Americans who
identify themselves as “black only.”
 37.7 million identify themselves as “black
and at least one other race.”
 11.5% of Texans are African Americans.


Treatment Issues for African
American
Assess for co-occurring substance use
disorders and alcoholism.
 Address complications of obesity,
hypertension, diabetes,congestive heart
failure, asthma, and cancer.
 Sickle cell anemia is another illness
specific to African Americans.


Treatment Issues for African
Americans
Matriarchy; Mom or grandmother are the
dominant family figures.
 Lack of male role models and intact
families.
 Extended family or the Church may be
supports.


Treatment Issues for African
Americans


There is discrimination within their own
group based on skin color, hair texture,
class, values, etc.

Treatment Issues for Asians

Asians rarely seek help until its very severe.
Asians have extremely low admissions to state hospitals.
Mental illness is considered shameful. It’s hidden.
Is an interpreter needed?

Treatment Issues for Asians
Focus on physical symptoms.
 Asians are sensitive to medication.
 Give ½ the standard dose.
 Asians may use traditional healers and
herbal medicine.
 Asians may “flush” when drinking
alcohol.


Asian Consumers

Acupuncture has been used to treat
pain, schizophrenia, depression, and addictions.

Treatment Issues for Asians
Asian Cultures are patriarchal.
 The males in the family have the authority.
 Asians are more formal and inhibited in
their social behavior.


Older Adults

Treatment Issues for Older
Adults
Are they aware they need help?

Treatment Issues for Older
Adults
Is their mental illness caused by medicine?
 Do their medical problems cause or
complicate their mental illness?
 Is there Elder Abuse?


Gay Men and Lesbian Women
May struggle with homophobia and“being in the
closet” at work and with their families.
Gay people may want marriage, children, partner
benefits, etc., but may endure legal barriers.

Gay and Lesbian Women
Gay people often have specific health
issues related to their sexual practices.
 HIV, AIDS and STD’s are still concerns
with Gay men.
 People may be grieving the death of a
partner or friends who’ve died from AIDS,
or coping with living with AIDS or being
HIV+ themselves.


Treatment Issues for Gay and
Lesbians
Explore childhood abuse issues and
Domestic Violence..
 Assess for substance use and alcoholism.
 Sex enhancing drug use may be common
among some gay men.


Physically Challenged
Can they get to treatment?
Deal with their frustration and depression
Re: their disability.
 Do they need vocational assistance?

Mentally Challenged

Treatment Issues of Mentally
Challenged
They need to have meaningful activity
and purpose in their lives.
 They need to feel acknowledged and
appreciated.
 They need safety, structure, and security.
 Lack of continuity can cause crisis!
 They may need vocational assistance.


Winona Ryder

December 12, 2001,
Winona Ryder shoplifted
$5,560.40 designer items
from Saks Fifth Avenue in
Beverley Hills.

Twice an Academy
Award Nominated
actress

She had the following 8 drugs in
her possession:
Liquid demerol
 Liquid Diazepam
 Vicodin
 Percodan
 Valium
 Morphine sulfate
 Endocet (containing Oxycodone)


Patterns of Drug Use are highly
Regional.
 Drugs,

routes of administration, street
names, patterns of use, and drug
combinations may differ greatly, not
only between individuals from
different cultures, but different parts
of the country or even different parts
of the city.

Drugs of Choice
Native Americans-alcohol
 Asians-gambling, work
 Gay Men-stimulants, amyl nitrate, ecstasy
 “Rich”-prescription drugs, Internet porn
 M.D.’s –Vicodin


Drugs of Choice
Young adults-marijuana, cigarettes
 Geriatrics-alcohol, pills
 Sex Workers-crack cocaine, IV speedballs
 Screen mentally retarded for abuse too!


How Do We Best Serve Our
Consumers?




Examine own stereotypes.
Build trust.
Use People First language!

How do we best serve our
consumers?
Pronounce the person’s name correctly.
 Get an interpreter, if necessary.
 Educate yourself from the consumer, his
family, co-workers, etc.
 Remember differences do matter!



Slide 25

Cultural Competence
Integrating Differences
into Community Services

Objectives
Understand Stigma.
 Understand Culture Competency.
 Learn Culturally competent care for
people with Mental Health, Mental
Retardation and Addictions.


We live in an world
which often separates us.
Racism
 Sexism
 Ageism
 Feminism
 Classism
 Atheism


“Different” people are
“Stigmatized”

Mentally retarded inmates in a sanitorium in Germany

Stigma
Definitions from the U. of Chicago PSR Training Manual

“Stigmas are negative attitudes about a
group that lead to depriving them of
some fair opportunities.”

Stigma is related to…..
Stereotypes
Prejudice
Discrimination

Stereotypes
from The Asian Health Coalition of Illinois

Stereotypes are exaggerated beliefs
or fixed ideas about a person or
group which is held by people and
sustained by selective perception and
selective forgetting.

Prejudice
from The Asian Health Coalition of Illinois

Prejudice is a preconceived idea or
negative attitude formed before the
facts are known and sustained over
generalizations. A bias without
reason, resisting all evidence…

Discrimination
from The Asian Health Coalition of Illinois

Discrimination refers to treatment in
favor or against a person based on
the group to which that person
belongs and not on merit.

Stigmatized People…..
Experience being stereotyped and
are often the object of
discrimination and prejudice.

People are often stigmatized by:













Mental Illness
Mental Retardation
Physical Disability (including blindness, deafness)
Alcoholism /and or Drug Addiction
HIV or AIDS, Cancer or other terminal illnesses
Criminal behavior
Poverty
Alternative Lifestyles/sexual orientation
Wheelchair bound
Gender
Obesity

All our Consumers belong to
stigmatized groups!

Stigmatized People
Consumers and their families
can’t navigate the bureaucracy
even if resources are there.
It’s too frustrating!

Use People First Language
“I am more than my
illness….Don’t call me
“the schizophrenic,
“the addict” or
“the retard.”

As human beings, we have many
similarities…..
But, who we really are, is often
derived from our original family of origin
and our current lifestyle.

The Bottom Line:
People are different, even within
their own culture!
These differences matter when
planning and providing services.

National Mental Health
Association
“For Mental Health consumers, both
access to the services and the effectiveness
of the care they receive are greatly affected
by the degree to which the delivery system
is“culturally competent.”

Some important definitions
Related to Cultural Competency

Culture

from King,et. al

The Office of Special Programs, U.S. Dept. of Education

“The integrated patterns of human
behavior that includes thoughts,
communications, actions, customs,
beliefs,values, and institutions of
racial, ethnic, religious, or social
groups.”

Cultural Sensitivity
An awareness and respect of a
person’s cultural beliefs and
values.
Culhane-Pera, et .al

Cultural Competency
 Skills

(that translate into)
 Behaviors, Practices, Attitudes, and
 Policies
That enable an individual, agency, or
system to effectively serve culturally
diverse communities.
from The Asian Health Coalition of Illinois

Here at Hill Country MHDDC
Consumers are very diverse in their
language and culture.

61% of our Consumers are
Caucasian Americans
Many have German
backgrounds.

Our Consumers are …..

n
1% NativeAmerican

33% Hispanic
1% Asian

3% African
American

1% are “Others”

Consumers Have Many
Different Lifestyles

Lifestyles

They have many different
beliefs.

Can We Communicate?
Think Language first!
 Do we need an interpreter?
 Communicate respectfully.
 Be sensitive to the consumer and the family.
 Consider your dress, tone of voice, eye contact,
location, seating arrangement, privacy, etc.


Is our approach culturally
appropriate?
“What do you call your problem?”
“What name does it have?”
“What do you think caused your problem?”
“Why do you think it started when it did?”
From Arthur Kleinman’s question protocol in“Culture,Illness, and Care:
Clinical Lessons from Anthropologic and Cross Cultural Research”,
Ann.Intern.Med. 1978:Vol.88, pg.251-258

Important Issues to Consider…





Impact of religion.
How are women, men, elders, and children
treated in their culture?
Is there domestic violence?
Ethnic minorities generally underutilize
outpatient services, although African-Americans
are over-represented in inpatient setting.

Diagnosis






Minorities with Bipolar Disorder are often
diagnosed with schizophrenia. (Mukherjee,et al)
African Americans are over diagnosed with
schizophrenia and under diagnosed with mood
disorders. (Bell )
A mental health consumer’s addictions may not
be treated.
The elderly may not be assessed for substance
abuse or alcoholism.

Diagnosis
A person with a primary addiction problem
might not be treated for a co-occurring mental
illness.
 Learning disabilities may not be identified in
individuals with mental illness or substance
abuse.
 A person with mental retardation may not be
treated for mental illness or substance abuse.


Diagnosis
Post Traumatic Stress Disorder is often
undiagnosed in people suffering from
Domestic Abuse or other trauma.
 Children who are witnessing or are
victims of domestic abuse or another
trauma, may be misdiagnosed with
Attention Deficit Hyperactivity Disorder.


Medication Differences





Asians and Hispanics need lower doses of antipsychotics.
African Americans use the same doses of antipsychotics, but lower doses of lithium.
The elderly need lower dosages of medications.
Thus, metabolism of drugs varies with age and
ethnicity and is critical in prescribing
medications.

From “Making Room for Culture in Psychiatry” by Lin, et al.

Pain Tolerance
Men and women tolerate pain differently.
 Cultures tolerate pain differently.
 People with addictions develop a
hypersensitivity to pain.
 In certain cultures, self-inflicted pain is a
part of a religious experience.


Religion





Religious beliefs shape how the world is viewed.
Is illness a punishment? The devil’s work? An
evil spell? Bad karma?
For Hispanics, the curandero is a trusted healer.
For Lakota Sioux, the ritual Vision Quest,
praying and fasting at a holy site is life
changing.

Remember there are as many
differences
Between individuals in the same
culture as there are between
individuals in different cultures!

Two African American
families, one lesbian
and the other, multi-racial.

German Consumers
Suggestions from our Gillespie County MH staff

What generation German?
 Would they feel more comfortable
speaking in German?


A consumer reacting to internal stimuli.

German Consumers
Suggestions from our Gillespie MHC staff in Fredericksburg

They may be resistant to seeking
mental services.
They may be reluctant to take medication.
They may “keep things within the family.”
They are concerned about the stigma.

German Consumers
They may feel it’s a character flaw or a
disgrace.
 They are very concerned about
confidentiality.
 Drinking alcohol is an accepted part of
their culture.
 Teen drinking may be acceptable in their
family.


Hispanic Consumers
from the U.S. Census, 1/23/03 Houston Chronicle

Hispanics are the largest minority group in
the U.S. with 37 million people.
 Texas is approximately 32 percent
Hispanic
 11.5 % African American,
 3.3% Other
 53.1% Anglo


Treatment Issues for Hispanic
Consumers
Do we need an interpreter?
 Is the person Tejano or from Mexico?
What generation Hispanic?
Is the person using a curandero?

Treatment issues for Hispanic
Consumers
Hallucinations are natural in their
religion.
 Hearing the voice of a loved one or having
hallucinations might be an expectations
when celebrating the Day of the Dead.
 Hispanic families are patriarchal.


Hispanic Consumers and
The Day of the Dead
A man is dressed in a skeleton
costume to portray death
in a celebration of
Dia de los Muertos,
The Day of the Dead.
People visit the graves of their
dead relatives to honor them.

Native Americans

Treatment Issues for Native
American Consumers
 Impact of racism,unemployment,and poverty.
 Coping with reservation life and
assimilation in mainstream culture.
 Consider the obesity, diabetes,
hypertension, and alcoholism in adults
and fetal alcohol syndrome in children.
 High use of native healers in the Southwest.

African Americans

African Americans
from the Houston Chronicle, 1/23/03

There are 36.2 million Americans who
identify themselves as “black only.”
 37.7 million identify themselves as “black
and at least one other race.”
 11.5% of Texans are African Americans.


Treatment Issues for African
American
Assess for co-occurring substance use
disorders and alcoholism.
 Address complications of obesity,
hypertension, diabetes,congestive heart
failure, asthma, and cancer.
 Sickle cell anemia is another illness
specific to African Americans.


Treatment Issues for African
Americans
Matriarchy; Mom or grandmother are the
dominant family figures.
 Lack of male role models and intact
families.
 Extended family or the Church may be
supports.


Treatment Issues for African
Americans


There is discrimination within their own
group based on skin color, hair texture,
class, values, etc.

Treatment Issues for Asians

Asians rarely seek help until its very severe.
Asians have extremely low admissions to state hospitals.
Mental illness is considered shameful. It’s hidden.
Is an interpreter needed?

Treatment Issues for Asians
Focus on physical symptoms.
 Asians are sensitive to medication.
 Give ½ the standard dose.
 Asians may use traditional healers and
herbal medicine.
 Asians may “flush” when drinking
alcohol.


Asian Consumers

Acupuncture has been used to treat
pain, schizophrenia, depression, and addictions.

Treatment Issues for Asians
Asian Cultures are patriarchal.
 The males in the family have the authority.
 Asians are more formal and inhibited in
their social behavior.


Older Adults

Treatment Issues for Older
Adults
Are they aware they need help?

Treatment Issues for Older
Adults
Is their mental illness caused by medicine?
 Do their medical problems cause or
complicate their mental illness?
 Is there Elder Abuse?


Gay Men and Lesbian Women
May struggle with homophobia and“being in the
closet” at work and with their families.
Gay people may want marriage, children, partner
benefits, etc., but may endure legal barriers.

Gay and Lesbian Women
Gay people often have specific health
issues related to their sexual practices.
 HIV, AIDS and STD’s are still concerns
with Gay men.
 People may be grieving the death of a
partner or friends who’ve died from AIDS,
or coping with living with AIDS or being
HIV+ themselves.


Treatment Issues for Gay and
Lesbians
Explore childhood abuse issues and
Domestic Violence..
 Assess for substance use and alcoholism.
 Sex enhancing drug use may be common
among some gay men.


Physically Challenged
Can they get to treatment?
Deal with their frustration and depression
Re: their disability.
 Do they need vocational assistance?

Mentally Challenged

Treatment Issues of Mentally
Challenged
They need to have meaningful activity
and purpose in their lives.
 They need to feel acknowledged and
appreciated.
 They need safety, structure, and security.
 Lack of continuity can cause crisis!
 They may need vocational assistance.


Winona Ryder

December 12, 2001,
Winona Ryder shoplifted
$5,560.40 designer items
from Saks Fifth Avenue in
Beverley Hills.

Twice an Academy
Award Nominated
actress

She had the following 8 drugs in
her possession:
Liquid demerol
 Liquid Diazepam
 Vicodin
 Percodan
 Valium
 Morphine sulfate
 Endocet (containing Oxycodone)


Patterns of Drug Use are highly
Regional.
 Drugs,

routes of administration, street
names, patterns of use, and drug
combinations may differ greatly, not
only between individuals from
different cultures, but different parts
of the country or even different parts
of the city.

Drugs of Choice
Native Americans-alcohol
 Asians-gambling, work
 Gay Men-stimulants, amyl nitrate, ecstasy
 “Rich”-prescription drugs, Internet porn
 M.D.’s –Vicodin


Drugs of Choice
Young adults-marijuana, cigarettes
 Geriatrics-alcohol, pills
 Sex Workers-crack cocaine, IV speedballs
 Screen mentally retarded for abuse too!


How Do We Best Serve Our
Consumers?




Examine own stereotypes.
Build trust.
Use People First language!

How do we best serve our
consumers?
Pronounce the person’s name correctly.
 Get an interpreter, if necessary.
 Educate yourself from the consumer, his
family, co-workers, etc.
 Remember differences do matter!



Slide 26

Cultural Competence
Integrating Differences
into Community Services

Objectives
Understand Stigma.
 Understand Culture Competency.
 Learn Culturally competent care for
people with Mental Health, Mental
Retardation and Addictions.


We live in an world
which often separates us.
Racism
 Sexism
 Ageism
 Feminism
 Classism
 Atheism


“Different” people are
“Stigmatized”

Mentally retarded inmates in a sanitorium in Germany

Stigma
Definitions from the U. of Chicago PSR Training Manual

“Stigmas are negative attitudes about a
group that lead to depriving them of
some fair opportunities.”

Stigma is related to…..
Stereotypes
Prejudice
Discrimination

Stereotypes
from The Asian Health Coalition of Illinois

Stereotypes are exaggerated beliefs
or fixed ideas about a person or
group which is held by people and
sustained by selective perception and
selective forgetting.

Prejudice
from The Asian Health Coalition of Illinois

Prejudice is a preconceived idea or
negative attitude formed before the
facts are known and sustained over
generalizations. A bias without
reason, resisting all evidence…

Discrimination
from The Asian Health Coalition of Illinois

Discrimination refers to treatment in
favor or against a person based on
the group to which that person
belongs and not on merit.

Stigmatized People…..
Experience being stereotyped and
are often the object of
discrimination and prejudice.

People are often stigmatized by:













Mental Illness
Mental Retardation
Physical Disability (including blindness, deafness)
Alcoholism /and or Drug Addiction
HIV or AIDS, Cancer or other terminal illnesses
Criminal behavior
Poverty
Alternative Lifestyles/sexual orientation
Wheelchair bound
Gender
Obesity

All our Consumers belong to
stigmatized groups!

Stigmatized People
Consumers and their families
can’t navigate the bureaucracy
even if resources are there.
It’s too frustrating!

Use People First Language
“I am more than my
illness….Don’t call me
“the schizophrenic,
“the addict” or
“the retard.”

As human beings, we have many
similarities…..
But, who we really are, is often
derived from our original family of origin
and our current lifestyle.

The Bottom Line:
People are different, even within
their own culture!
These differences matter when
planning and providing services.

National Mental Health
Association
“For Mental Health consumers, both
access to the services and the effectiveness
of the care they receive are greatly affected
by the degree to which the delivery system
is“culturally competent.”

Some important definitions
Related to Cultural Competency

Culture

from King,et. al

The Office of Special Programs, U.S. Dept. of Education

“The integrated patterns of human
behavior that includes thoughts,
communications, actions, customs,
beliefs,values, and institutions of
racial, ethnic, religious, or social
groups.”

Cultural Sensitivity
An awareness and respect of a
person’s cultural beliefs and
values.
Culhane-Pera, et .al

Cultural Competency
 Skills

(that translate into)
 Behaviors, Practices, Attitudes, and
 Policies
That enable an individual, agency, or
system to effectively serve culturally
diverse communities.
from The Asian Health Coalition of Illinois

Here at Hill Country MHDDC
Consumers are very diverse in their
language and culture.

61% of our Consumers are
Caucasian Americans
Many have German
backgrounds.

Our Consumers are …..

n
1% NativeAmerican

33% Hispanic
1% Asian

3% African
American

1% are “Others”

Consumers Have Many
Different Lifestyles

Lifestyles

They have many different
beliefs.

Can We Communicate?
Think Language first!
 Do we need an interpreter?
 Communicate respectfully.
 Be sensitive to the consumer and the family.
 Consider your dress, tone of voice, eye contact,
location, seating arrangement, privacy, etc.


Is our approach culturally
appropriate?
“What do you call your problem?”
“What name does it have?”
“What do you think caused your problem?”
“Why do you think it started when it did?”
From Arthur Kleinman’s question protocol in“Culture,Illness, and Care:
Clinical Lessons from Anthropologic and Cross Cultural Research”,
Ann.Intern.Med. 1978:Vol.88, pg.251-258

Important Issues to Consider…





Impact of religion.
How are women, men, elders, and children
treated in their culture?
Is there domestic violence?
Ethnic minorities generally underutilize
outpatient services, although African-Americans
are over-represented in inpatient setting.

Diagnosis






Minorities with Bipolar Disorder are often
diagnosed with schizophrenia. (Mukherjee,et al)
African Americans are over diagnosed with
schizophrenia and under diagnosed with mood
disorders. (Bell )
A mental health consumer’s addictions may not
be treated.
The elderly may not be assessed for substance
abuse or alcoholism.

Diagnosis
A person with a primary addiction problem
might not be treated for a co-occurring mental
illness.
 Learning disabilities may not be identified in
individuals with mental illness or substance
abuse.
 A person with mental retardation may not be
treated for mental illness or substance abuse.


Diagnosis
Post Traumatic Stress Disorder is often
undiagnosed in people suffering from
Domestic Abuse or other trauma.
 Children who are witnessing or are
victims of domestic abuse or another
trauma, may be misdiagnosed with
Attention Deficit Hyperactivity Disorder.


Medication Differences





Asians and Hispanics need lower doses of antipsychotics.
African Americans use the same doses of antipsychotics, but lower doses of lithium.
The elderly need lower dosages of medications.
Thus, metabolism of drugs varies with age and
ethnicity and is critical in prescribing
medications.

From “Making Room for Culture in Psychiatry” by Lin, et al.

Pain Tolerance
Men and women tolerate pain differently.
 Cultures tolerate pain differently.
 People with addictions develop a
hypersensitivity to pain.
 In certain cultures, self-inflicted pain is a
part of a religious experience.


Religion





Religious beliefs shape how the world is viewed.
Is illness a punishment? The devil’s work? An
evil spell? Bad karma?
For Hispanics, the curandero is a trusted healer.
For Lakota Sioux, the ritual Vision Quest,
praying and fasting at a holy site is life
changing.

Remember there are as many
differences
Between individuals in the same
culture as there are between
individuals in different cultures!

Two African American
families, one lesbian
and the other, multi-racial.

German Consumers
Suggestions from our Gillespie County MH staff

What generation German?
 Would they feel more comfortable
speaking in German?


A consumer reacting to internal stimuli.

German Consumers
Suggestions from our Gillespie MHC staff in Fredericksburg

They may be resistant to seeking
mental services.
They may be reluctant to take medication.
They may “keep things within the family.”
They are concerned about the stigma.

German Consumers
They may feel it’s a character flaw or a
disgrace.
 They are very concerned about
confidentiality.
 Drinking alcohol is an accepted part of
their culture.
 Teen drinking may be acceptable in their
family.


Hispanic Consumers
from the U.S. Census, 1/23/03 Houston Chronicle

Hispanics are the largest minority group in
the U.S. with 37 million people.
 Texas is approximately 32 percent
Hispanic
 11.5 % African American,
 3.3% Other
 53.1% Anglo


Treatment Issues for Hispanic
Consumers
Do we need an interpreter?
 Is the person Tejano or from Mexico?
What generation Hispanic?
Is the person using a curandero?

Treatment issues for Hispanic
Consumers
Hallucinations are natural in their
religion.
 Hearing the voice of a loved one or having
hallucinations might be an expectations
when celebrating the Day of the Dead.
 Hispanic families are patriarchal.


Hispanic Consumers and
The Day of the Dead
A man is dressed in a skeleton
costume to portray death
in a celebration of
Dia de los Muertos,
The Day of the Dead.
People visit the graves of their
dead relatives to honor them.

Native Americans

Treatment Issues for Native
American Consumers
 Impact of racism,unemployment,and poverty.
 Coping with reservation life and
assimilation in mainstream culture.
 Consider the obesity, diabetes,
hypertension, and alcoholism in adults
and fetal alcohol syndrome in children.
 High use of native healers in the Southwest.

African Americans

African Americans
from the Houston Chronicle, 1/23/03

There are 36.2 million Americans who
identify themselves as “black only.”
 37.7 million identify themselves as “black
and at least one other race.”
 11.5% of Texans are African Americans.


Treatment Issues for African
American
Assess for co-occurring substance use
disorders and alcoholism.
 Address complications of obesity,
hypertension, diabetes,congestive heart
failure, asthma, and cancer.
 Sickle cell anemia is another illness
specific to African Americans.


Treatment Issues for African
Americans
Matriarchy; Mom or grandmother are the
dominant family figures.
 Lack of male role models and intact
families.
 Extended family or the Church may be
supports.


Treatment Issues for African
Americans


There is discrimination within their own
group based on skin color, hair texture,
class, values, etc.

Treatment Issues for Asians

Asians rarely seek help until its very severe.
Asians have extremely low admissions to state hospitals.
Mental illness is considered shameful. It’s hidden.
Is an interpreter needed?

Treatment Issues for Asians
Focus on physical symptoms.
 Asians are sensitive to medication.
 Give ½ the standard dose.
 Asians may use traditional healers and
herbal medicine.
 Asians may “flush” when drinking
alcohol.


Asian Consumers

Acupuncture has been used to treat
pain, schizophrenia, depression, and addictions.

Treatment Issues for Asians
Asian Cultures are patriarchal.
 The males in the family have the authority.
 Asians are more formal and inhibited in
their social behavior.


Older Adults

Treatment Issues for Older
Adults
Are they aware they need help?

Treatment Issues for Older
Adults
Is their mental illness caused by medicine?
 Do their medical problems cause or
complicate their mental illness?
 Is there Elder Abuse?


Gay Men and Lesbian Women
May struggle with homophobia and“being in the
closet” at work and with their families.
Gay people may want marriage, children, partner
benefits, etc., but may endure legal barriers.

Gay and Lesbian Women
Gay people often have specific health
issues related to their sexual practices.
 HIV, AIDS and STD’s are still concerns
with Gay men.
 People may be grieving the death of a
partner or friends who’ve died from AIDS,
or coping with living with AIDS or being
HIV+ themselves.


Treatment Issues for Gay and
Lesbians
Explore childhood abuse issues and
Domestic Violence..
 Assess for substance use and alcoholism.
 Sex enhancing drug use may be common
among some gay men.


Physically Challenged
Can they get to treatment?
Deal with their frustration and depression
Re: their disability.
 Do they need vocational assistance?

Mentally Challenged

Treatment Issues of Mentally
Challenged
They need to have meaningful activity
and purpose in their lives.
 They need to feel acknowledged and
appreciated.
 They need safety, structure, and security.
 Lack of continuity can cause crisis!
 They may need vocational assistance.


Winona Ryder

December 12, 2001,
Winona Ryder shoplifted
$5,560.40 designer items
from Saks Fifth Avenue in
Beverley Hills.

Twice an Academy
Award Nominated
actress

She had the following 8 drugs in
her possession:
Liquid demerol
 Liquid Diazepam
 Vicodin
 Percodan
 Valium
 Morphine sulfate
 Endocet (containing Oxycodone)


Patterns of Drug Use are highly
Regional.
 Drugs,

routes of administration, street
names, patterns of use, and drug
combinations may differ greatly, not
only between individuals from
different cultures, but different parts
of the country or even different parts
of the city.

Drugs of Choice
Native Americans-alcohol
 Asians-gambling, work
 Gay Men-stimulants, amyl nitrate, ecstasy
 “Rich”-prescription drugs, Internet porn
 M.D.’s –Vicodin


Drugs of Choice
Young adults-marijuana, cigarettes
 Geriatrics-alcohol, pills
 Sex Workers-crack cocaine, IV speedballs
 Screen mentally retarded for abuse too!


How Do We Best Serve Our
Consumers?




Examine own stereotypes.
Build trust.
Use People First language!

How do we best serve our
consumers?
Pronounce the person’s name correctly.
 Get an interpreter, if necessary.
 Educate yourself from the consumer, his
family, co-workers, etc.
 Remember differences do matter!



Slide 27

Cultural Competence
Integrating Differences
into Community Services

Objectives
Understand Stigma.
 Understand Culture Competency.
 Learn Culturally competent care for
people with Mental Health, Mental
Retardation and Addictions.


We live in an world
which often separates us.
Racism
 Sexism
 Ageism
 Feminism
 Classism
 Atheism


“Different” people are
“Stigmatized”

Mentally retarded inmates in a sanitorium in Germany

Stigma
Definitions from the U. of Chicago PSR Training Manual

“Stigmas are negative attitudes about a
group that lead to depriving them of
some fair opportunities.”

Stigma is related to…..
Stereotypes
Prejudice
Discrimination

Stereotypes
from The Asian Health Coalition of Illinois

Stereotypes are exaggerated beliefs
or fixed ideas about a person or
group which is held by people and
sustained by selective perception and
selective forgetting.

Prejudice
from The Asian Health Coalition of Illinois

Prejudice is a preconceived idea or
negative attitude formed before the
facts are known and sustained over
generalizations. A bias without
reason, resisting all evidence…

Discrimination
from The Asian Health Coalition of Illinois

Discrimination refers to treatment in
favor or against a person based on
the group to which that person
belongs and not on merit.

Stigmatized People…..
Experience being stereotyped and
are often the object of
discrimination and prejudice.

People are often stigmatized by:













Mental Illness
Mental Retardation
Physical Disability (including blindness, deafness)
Alcoholism /and or Drug Addiction
HIV or AIDS, Cancer or other terminal illnesses
Criminal behavior
Poverty
Alternative Lifestyles/sexual orientation
Wheelchair bound
Gender
Obesity

All our Consumers belong to
stigmatized groups!

Stigmatized People
Consumers and their families
can’t navigate the bureaucracy
even if resources are there.
It’s too frustrating!

Use People First Language
“I am more than my
illness….Don’t call me
“the schizophrenic,
“the addict” or
“the retard.”

As human beings, we have many
similarities…..
But, who we really are, is often
derived from our original family of origin
and our current lifestyle.

The Bottom Line:
People are different, even within
their own culture!
These differences matter when
planning and providing services.

National Mental Health
Association
“For Mental Health consumers, both
access to the services and the effectiveness
of the care they receive are greatly affected
by the degree to which the delivery system
is“culturally competent.”

Some important definitions
Related to Cultural Competency

Culture

from King,et. al

The Office of Special Programs, U.S. Dept. of Education

“The integrated patterns of human
behavior that includes thoughts,
communications, actions, customs,
beliefs,values, and institutions of
racial, ethnic, religious, or social
groups.”

Cultural Sensitivity
An awareness and respect of a
person’s cultural beliefs and
values.
Culhane-Pera, et .al

Cultural Competency
 Skills

(that translate into)
 Behaviors, Practices, Attitudes, and
 Policies
That enable an individual, agency, or
system to effectively serve culturally
diverse communities.
from The Asian Health Coalition of Illinois

Here at Hill Country MHDDC
Consumers are very diverse in their
language and culture.

61% of our Consumers are
Caucasian Americans
Many have German
backgrounds.

Our Consumers are …..

n
1% NativeAmerican

33% Hispanic
1% Asian

3% African
American

1% are “Others”

Consumers Have Many
Different Lifestyles

Lifestyles

They have many different
beliefs.

Can We Communicate?
Think Language first!
 Do we need an interpreter?
 Communicate respectfully.
 Be sensitive to the consumer and the family.
 Consider your dress, tone of voice, eye contact,
location, seating arrangement, privacy, etc.


Is our approach culturally
appropriate?
“What do you call your problem?”
“What name does it have?”
“What do you think caused your problem?”
“Why do you think it started when it did?”
From Arthur Kleinman’s question protocol in“Culture,Illness, and Care:
Clinical Lessons from Anthropologic and Cross Cultural Research”,
Ann.Intern.Med. 1978:Vol.88, pg.251-258

Important Issues to Consider…





Impact of religion.
How are women, men, elders, and children
treated in their culture?
Is there domestic violence?
Ethnic minorities generally underutilize
outpatient services, although African-Americans
are over-represented in inpatient setting.

Diagnosis






Minorities with Bipolar Disorder are often
diagnosed with schizophrenia. (Mukherjee,et al)
African Americans are over diagnosed with
schizophrenia and under diagnosed with mood
disorders. (Bell )
A mental health consumer’s addictions may not
be treated.
The elderly may not be assessed for substance
abuse or alcoholism.

Diagnosis
A person with a primary addiction problem
might not be treated for a co-occurring mental
illness.
 Learning disabilities may not be identified in
individuals with mental illness or substance
abuse.
 A person with mental retardation may not be
treated for mental illness or substance abuse.


Diagnosis
Post Traumatic Stress Disorder is often
undiagnosed in people suffering from
Domestic Abuse or other trauma.
 Children who are witnessing or are
victims of domestic abuse or another
trauma, may be misdiagnosed with
Attention Deficit Hyperactivity Disorder.


Medication Differences





Asians and Hispanics need lower doses of antipsychotics.
African Americans use the same doses of antipsychotics, but lower doses of lithium.
The elderly need lower dosages of medications.
Thus, metabolism of drugs varies with age and
ethnicity and is critical in prescribing
medications.

From “Making Room for Culture in Psychiatry” by Lin, et al.

Pain Tolerance
Men and women tolerate pain differently.
 Cultures tolerate pain differently.
 People with addictions develop a
hypersensitivity to pain.
 In certain cultures, self-inflicted pain is a
part of a religious experience.


Religion





Religious beliefs shape how the world is viewed.
Is illness a punishment? The devil’s work? An
evil spell? Bad karma?
For Hispanics, the curandero is a trusted healer.
For Lakota Sioux, the ritual Vision Quest,
praying and fasting at a holy site is life
changing.

Remember there are as many
differences
Between individuals in the same
culture as there are between
individuals in different cultures!

Two African American
families, one lesbian
and the other, multi-racial.

German Consumers
Suggestions from our Gillespie County MH staff

What generation German?
 Would they feel more comfortable
speaking in German?


A consumer reacting to internal stimuli.

German Consumers
Suggestions from our Gillespie MHC staff in Fredericksburg

They may be resistant to seeking
mental services.
They may be reluctant to take medication.
They may “keep things within the family.”
They are concerned about the stigma.

German Consumers
They may feel it’s a character flaw or a
disgrace.
 They are very concerned about
confidentiality.
 Drinking alcohol is an accepted part of
their culture.
 Teen drinking may be acceptable in their
family.


Hispanic Consumers
from the U.S. Census, 1/23/03 Houston Chronicle

Hispanics are the largest minority group in
the U.S. with 37 million people.
 Texas is approximately 32 percent
Hispanic
 11.5 % African American,
 3.3% Other
 53.1% Anglo


Treatment Issues for Hispanic
Consumers
Do we need an interpreter?
 Is the person Tejano or from Mexico?
What generation Hispanic?
Is the person using a curandero?

Treatment issues for Hispanic
Consumers
Hallucinations are natural in their
religion.
 Hearing the voice of a loved one or having
hallucinations might be an expectations
when celebrating the Day of the Dead.
 Hispanic families are patriarchal.


Hispanic Consumers and
The Day of the Dead
A man is dressed in a skeleton
costume to portray death
in a celebration of
Dia de los Muertos,
The Day of the Dead.
People visit the graves of their
dead relatives to honor them.

Native Americans

Treatment Issues for Native
American Consumers
 Impact of racism,unemployment,and poverty.
 Coping with reservation life and
assimilation in mainstream culture.
 Consider the obesity, diabetes,
hypertension, and alcoholism in adults
and fetal alcohol syndrome in children.
 High use of native healers in the Southwest.

African Americans

African Americans
from the Houston Chronicle, 1/23/03

There are 36.2 million Americans who
identify themselves as “black only.”
 37.7 million identify themselves as “black
and at least one other race.”
 11.5% of Texans are African Americans.


Treatment Issues for African
American
Assess for co-occurring substance use
disorders and alcoholism.
 Address complications of obesity,
hypertension, diabetes,congestive heart
failure, asthma, and cancer.
 Sickle cell anemia is another illness
specific to African Americans.


Treatment Issues for African
Americans
Matriarchy; Mom or grandmother are the
dominant family figures.
 Lack of male role models and intact
families.
 Extended family or the Church may be
supports.


Treatment Issues for African
Americans


There is discrimination within their own
group based on skin color, hair texture,
class, values, etc.

Treatment Issues for Asians

Asians rarely seek help until its very severe.
Asians have extremely low admissions to state hospitals.
Mental illness is considered shameful. It’s hidden.
Is an interpreter needed?

Treatment Issues for Asians
Focus on physical symptoms.
 Asians are sensitive to medication.
 Give ½ the standard dose.
 Asians may use traditional healers and
herbal medicine.
 Asians may “flush” when drinking
alcohol.


Asian Consumers

Acupuncture has been used to treat
pain, schizophrenia, depression, and addictions.

Treatment Issues for Asians
Asian Cultures are patriarchal.
 The males in the family have the authority.
 Asians are more formal and inhibited in
their social behavior.


Older Adults

Treatment Issues for Older
Adults
Are they aware they need help?

Treatment Issues for Older
Adults
Is their mental illness caused by medicine?
 Do their medical problems cause or
complicate their mental illness?
 Is there Elder Abuse?


Gay Men and Lesbian Women
May struggle with homophobia and“being in the
closet” at work and with their families.
Gay people may want marriage, children, partner
benefits, etc., but may endure legal barriers.

Gay and Lesbian Women
Gay people often have specific health
issues related to their sexual practices.
 HIV, AIDS and STD’s are still concerns
with Gay men.
 People may be grieving the death of a
partner or friends who’ve died from AIDS,
or coping with living with AIDS or being
HIV+ themselves.


Treatment Issues for Gay and
Lesbians
Explore childhood abuse issues and
Domestic Violence..
 Assess for substance use and alcoholism.
 Sex enhancing drug use may be common
among some gay men.


Physically Challenged
Can they get to treatment?
Deal with their frustration and depression
Re: their disability.
 Do they need vocational assistance?

Mentally Challenged

Treatment Issues of Mentally
Challenged
They need to have meaningful activity
and purpose in their lives.
 They need to feel acknowledged and
appreciated.
 They need safety, structure, and security.
 Lack of continuity can cause crisis!
 They may need vocational assistance.


Winona Ryder

December 12, 2001,
Winona Ryder shoplifted
$5,560.40 designer items
from Saks Fifth Avenue in
Beverley Hills.

Twice an Academy
Award Nominated
actress

She had the following 8 drugs in
her possession:
Liquid demerol
 Liquid Diazepam
 Vicodin
 Percodan
 Valium
 Morphine sulfate
 Endocet (containing Oxycodone)


Patterns of Drug Use are highly
Regional.
 Drugs,

routes of administration, street
names, patterns of use, and drug
combinations may differ greatly, not
only between individuals from
different cultures, but different parts
of the country or even different parts
of the city.

Drugs of Choice
Native Americans-alcohol
 Asians-gambling, work
 Gay Men-stimulants, amyl nitrate, ecstasy
 “Rich”-prescription drugs, Internet porn
 M.D.’s –Vicodin


Drugs of Choice
Young adults-marijuana, cigarettes
 Geriatrics-alcohol, pills
 Sex Workers-crack cocaine, IV speedballs
 Screen mentally retarded for abuse too!


How Do We Best Serve Our
Consumers?




Examine own stereotypes.
Build trust.
Use People First language!

How do we best serve our
consumers?
Pronounce the person’s name correctly.
 Get an interpreter, if necessary.
 Educate yourself from the consumer, his
family, co-workers, etc.
 Remember differences do matter!



Slide 28

Cultural Competence
Integrating Differences
into Community Services

Objectives
Understand Stigma.
 Understand Culture Competency.
 Learn Culturally competent care for
people with Mental Health, Mental
Retardation and Addictions.


We live in an world
which often separates us.
Racism
 Sexism
 Ageism
 Feminism
 Classism
 Atheism


“Different” people are
“Stigmatized”

Mentally retarded inmates in a sanitorium in Germany

Stigma
Definitions from the U. of Chicago PSR Training Manual

“Stigmas are negative attitudes about a
group that lead to depriving them of
some fair opportunities.”

Stigma is related to…..
Stereotypes
Prejudice
Discrimination

Stereotypes
from The Asian Health Coalition of Illinois

Stereotypes are exaggerated beliefs
or fixed ideas about a person or
group which is held by people and
sustained by selective perception and
selective forgetting.

Prejudice
from The Asian Health Coalition of Illinois

Prejudice is a preconceived idea or
negative attitude formed before the
facts are known and sustained over
generalizations. A bias without
reason, resisting all evidence…

Discrimination
from The Asian Health Coalition of Illinois

Discrimination refers to treatment in
favor or against a person based on
the group to which that person
belongs and not on merit.

Stigmatized People…..
Experience being stereotyped and
are often the object of
discrimination and prejudice.

People are often stigmatized by:













Mental Illness
Mental Retardation
Physical Disability (including blindness, deafness)
Alcoholism /and or Drug Addiction
HIV or AIDS, Cancer or other terminal illnesses
Criminal behavior
Poverty
Alternative Lifestyles/sexual orientation
Wheelchair bound
Gender
Obesity

All our Consumers belong to
stigmatized groups!

Stigmatized People
Consumers and their families
can’t navigate the bureaucracy
even if resources are there.
It’s too frustrating!

Use People First Language
“I am more than my
illness….Don’t call me
“the schizophrenic,
“the addict” or
“the retard.”

As human beings, we have many
similarities…..
But, who we really are, is often
derived from our original family of origin
and our current lifestyle.

The Bottom Line:
People are different, even within
their own culture!
These differences matter when
planning and providing services.

National Mental Health
Association
“For Mental Health consumers, both
access to the services and the effectiveness
of the care they receive are greatly affected
by the degree to which the delivery system
is“culturally competent.”

Some important definitions
Related to Cultural Competency

Culture

from King,et. al

The Office of Special Programs, U.S. Dept. of Education

“The integrated patterns of human
behavior that includes thoughts,
communications, actions, customs,
beliefs,values, and institutions of
racial, ethnic, religious, or social
groups.”

Cultural Sensitivity
An awareness and respect of a
person’s cultural beliefs and
values.
Culhane-Pera, et .al

Cultural Competency
 Skills

(that translate into)
 Behaviors, Practices, Attitudes, and
 Policies
That enable an individual, agency, or
system to effectively serve culturally
diverse communities.
from The Asian Health Coalition of Illinois

Here at Hill Country MHDDC
Consumers are very diverse in their
language and culture.

61% of our Consumers are
Caucasian Americans
Many have German
backgrounds.

Our Consumers are …..

n
1% NativeAmerican

33% Hispanic
1% Asian

3% African
American

1% are “Others”

Consumers Have Many
Different Lifestyles

Lifestyles

They have many different
beliefs.

Can We Communicate?
Think Language first!
 Do we need an interpreter?
 Communicate respectfully.
 Be sensitive to the consumer and the family.
 Consider your dress, tone of voice, eye contact,
location, seating arrangement, privacy, etc.


Is our approach culturally
appropriate?
“What do you call your problem?”
“What name does it have?”
“What do you think caused your problem?”
“Why do you think it started when it did?”
From Arthur Kleinman’s question protocol in“Culture,Illness, and Care:
Clinical Lessons from Anthropologic and Cross Cultural Research”,
Ann.Intern.Med. 1978:Vol.88, pg.251-258

Important Issues to Consider…





Impact of religion.
How are women, men, elders, and children
treated in their culture?
Is there domestic violence?
Ethnic minorities generally underutilize
outpatient services, although African-Americans
are over-represented in inpatient setting.

Diagnosis






Minorities with Bipolar Disorder are often
diagnosed with schizophrenia. (Mukherjee,et al)
African Americans are over diagnosed with
schizophrenia and under diagnosed with mood
disorders. (Bell )
A mental health consumer’s addictions may not
be treated.
The elderly may not be assessed for substance
abuse or alcoholism.

Diagnosis
A person with a primary addiction problem
might not be treated for a co-occurring mental
illness.
 Learning disabilities may not be identified in
individuals with mental illness or substance
abuse.
 A person with mental retardation may not be
treated for mental illness or substance abuse.


Diagnosis
Post Traumatic Stress Disorder is often
undiagnosed in people suffering from
Domestic Abuse or other trauma.
 Children who are witnessing or are
victims of domestic abuse or another
trauma, may be misdiagnosed with
Attention Deficit Hyperactivity Disorder.


Medication Differences





Asians and Hispanics need lower doses of antipsychotics.
African Americans use the same doses of antipsychotics, but lower doses of lithium.
The elderly need lower dosages of medications.
Thus, metabolism of drugs varies with age and
ethnicity and is critical in prescribing
medications.

From “Making Room for Culture in Psychiatry” by Lin, et al.

Pain Tolerance
Men and women tolerate pain differently.
 Cultures tolerate pain differently.
 People with addictions develop a
hypersensitivity to pain.
 In certain cultures, self-inflicted pain is a
part of a religious experience.


Religion





Religious beliefs shape how the world is viewed.
Is illness a punishment? The devil’s work? An
evil spell? Bad karma?
For Hispanics, the curandero is a trusted healer.
For Lakota Sioux, the ritual Vision Quest,
praying and fasting at a holy site is life
changing.

Remember there are as many
differences
Between individuals in the same
culture as there are between
individuals in different cultures!

Two African American
families, one lesbian
and the other, multi-racial.

German Consumers
Suggestions from our Gillespie County MH staff

What generation German?
 Would they feel more comfortable
speaking in German?


A consumer reacting to internal stimuli.

German Consumers
Suggestions from our Gillespie MHC staff in Fredericksburg

They may be resistant to seeking
mental services.
They may be reluctant to take medication.
They may “keep things within the family.”
They are concerned about the stigma.

German Consumers
They may feel it’s a character flaw or a
disgrace.
 They are very concerned about
confidentiality.
 Drinking alcohol is an accepted part of
their culture.
 Teen drinking may be acceptable in their
family.


Hispanic Consumers
from the U.S. Census, 1/23/03 Houston Chronicle

Hispanics are the largest minority group in
the U.S. with 37 million people.
 Texas is approximately 32 percent
Hispanic
 11.5 % African American,
 3.3% Other
 53.1% Anglo


Treatment Issues for Hispanic
Consumers
Do we need an interpreter?
 Is the person Tejano or from Mexico?
What generation Hispanic?
Is the person using a curandero?

Treatment issues for Hispanic
Consumers
Hallucinations are natural in their
religion.
 Hearing the voice of a loved one or having
hallucinations might be an expectations
when celebrating the Day of the Dead.
 Hispanic families are patriarchal.


Hispanic Consumers and
The Day of the Dead
A man is dressed in a skeleton
costume to portray death
in a celebration of
Dia de los Muertos,
The Day of the Dead.
People visit the graves of their
dead relatives to honor them.

Native Americans

Treatment Issues for Native
American Consumers
 Impact of racism,unemployment,and poverty.
 Coping with reservation life and
assimilation in mainstream culture.
 Consider the obesity, diabetes,
hypertension, and alcoholism in adults
and fetal alcohol syndrome in children.
 High use of native healers in the Southwest.

African Americans

African Americans
from the Houston Chronicle, 1/23/03

There are 36.2 million Americans who
identify themselves as “black only.”
 37.7 million identify themselves as “black
and at least one other race.”
 11.5% of Texans are African Americans.


Treatment Issues for African
American
Assess for co-occurring substance use
disorders and alcoholism.
 Address complications of obesity,
hypertension, diabetes,congestive heart
failure, asthma, and cancer.
 Sickle cell anemia is another illness
specific to African Americans.


Treatment Issues for African
Americans
Matriarchy; Mom or grandmother are the
dominant family figures.
 Lack of male role models and intact
families.
 Extended family or the Church may be
supports.


Treatment Issues for African
Americans


There is discrimination within their own
group based on skin color, hair texture,
class, values, etc.

Treatment Issues for Asians

Asians rarely seek help until its very severe.
Asians have extremely low admissions to state hospitals.
Mental illness is considered shameful. It’s hidden.
Is an interpreter needed?

Treatment Issues for Asians
Focus on physical symptoms.
 Asians are sensitive to medication.
 Give ½ the standard dose.
 Asians may use traditional healers and
herbal medicine.
 Asians may “flush” when drinking
alcohol.


Asian Consumers

Acupuncture has been used to treat
pain, schizophrenia, depression, and addictions.

Treatment Issues for Asians
Asian Cultures are patriarchal.
 The males in the family have the authority.
 Asians are more formal and inhibited in
their social behavior.


Older Adults

Treatment Issues for Older
Adults
Are they aware they need help?

Treatment Issues for Older
Adults
Is their mental illness caused by medicine?
 Do their medical problems cause or
complicate their mental illness?
 Is there Elder Abuse?


Gay Men and Lesbian Women
May struggle with homophobia and“being in the
closet” at work and with their families.
Gay people may want marriage, children, partner
benefits, etc., but may endure legal barriers.

Gay and Lesbian Women
Gay people often have specific health
issues related to their sexual practices.
 HIV, AIDS and STD’s are still concerns
with Gay men.
 People may be grieving the death of a
partner or friends who’ve died from AIDS,
or coping with living with AIDS or being
HIV+ themselves.


Treatment Issues for Gay and
Lesbians
Explore childhood abuse issues and
Domestic Violence..
 Assess for substance use and alcoholism.
 Sex enhancing drug use may be common
among some gay men.


Physically Challenged
Can they get to treatment?
Deal with their frustration and depression
Re: their disability.
 Do they need vocational assistance?

Mentally Challenged

Treatment Issues of Mentally
Challenged
They need to have meaningful activity
and purpose in their lives.
 They need to feel acknowledged and
appreciated.
 They need safety, structure, and security.
 Lack of continuity can cause crisis!
 They may need vocational assistance.


Winona Ryder

December 12, 2001,
Winona Ryder shoplifted
$5,560.40 designer items
from Saks Fifth Avenue in
Beverley Hills.

Twice an Academy
Award Nominated
actress

She had the following 8 drugs in
her possession:
Liquid demerol
 Liquid Diazepam
 Vicodin
 Percodan
 Valium
 Morphine sulfate
 Endocet (containing Oxycodone)


Patterns of Drug Use are highly
Regional.
 Drugs,

routes of administration, street
names, patterns of use, and drug
combinations may differ greatly, not
only between individuals from
different cultures, but different parts
of the country or even different parts
of the city.

Drugs of Choice
Native Americans-alcohol
 Asians-gambling, work
 Gay Men-stimulants, amyl nitrate, ecstasy
 “Rich”-prescription drugs, Internet porn
 M.D.’s –Vicodin


Drugs of Choice
Young adults-marijuana, cigarettes
 Geriatrics-alcohol, pills
 Sex Workers-crack cocaine, IV speedballs
 Screen mentally retarded for abuse too!


How Do We Best Serve Our
Consumers?




Examine own stereotypes.
Build trust.
Use People First language!

How do we best serve our
consumers?
Pronounce the person’s name correctly.
 Get an interpreter, if necessary.
 Educate yourself from the consumer, his
family, co-workers, etc.
 Remember differences do matter!



Slide 29

Cultural Competence
Integrating Differences
into Community Services

Objectives
Understand Stigma.
 Understand Culture Competency.
 Learn Culturally competent care for
people with Mental Health, Mental
Retardation and Addictions.


We live in an world
which often separates us.
Racism
 Sexism
 Ageism
 Feminism
 Classism
 Atheism


“Different” people are
“Stigmatized”

Mentally retarded inmates in a sanitorium in Germany

Stigma
Definitions from the U. of Chicago PSR Training Manual

“Stigmas are negative attitudes about a
group that lead to depriving them of
some fair opportunities.”

Stigma is related to…..
Stereotypes
Prejudice
Discrimination

Stereotypes
from The Asian Health Coalition of Illinois

Stereotypes are exaggerated beliefs
or fixed ideas about a person or
group which is held by people and
sustained by selective perception and
selective forgetting.

Prejudice
from The Asian Health Coalition of Illinois

Prejudice is a preconceived idea or
negative attitude formed before the
facts are known and sustained over
generalizations. A bias without
reason, resisting all evidence…

Discrimination
from The Asian Health Coalition of Illinois

Discrimination refers to treatment in
favor or against a person based on
the group to which that person
belongs and not on merit.

Stigmatized People…..
Experience being stereotyped and
are often the object of
discrimination and prejudice.

People are often stigmatized by:













Mental Illness
Mental Retardation
Physical Disability (including blindness, deafness)
Alcoholism /and or Drug Addiction
HIV or AIDS, Cancer or other terminal illnesses
Criminal behavior
Poverty
Alternative Lifestyles/sexual orientation
Wheelchair bound
Gender
Obesity

All our Consumers belong to
stigmatized groups!

Stigmatized People
Consumers and their families
can’t navigate the bureaucracy
even if resources are there.
It’s too frustrating!

Use People First Language
“I am more than my
illness….Don’t call me
“the schizophrenic,
“the addict” or
“the retard.”

As human beings, we have many
similarities…..
But, who we really are, is often
derived from our original family of origin
and our current lifestyle.

The Bottom Line:
People are different, even within
their own culture!
These differences matter when
planning and providing services.

National Mental Health
Association
“For Mental Health consumers, both
access to the services and the effectiveness
of the care they receive are greatly affected
by the degree to which the delivery system
is“culturally competent.”

Some important definitions
Related to Cultural Competency

Culture

from King,et. al

The Office of Special Programs, U.S. Dept. of Education

“The integrated patterns of human
behavior that includes thoughts,
communications, actions, customs,
beliefs,values, and institutions of
racial, ethnic, religious, or social
groups.”

Cultural Sensitivity
An awareness and respect of a
person’s cultural beliefs and
values.
Culhane-Pera, et .al

Cultural Competency
 Skills

(that translate into)
 Behaviors, Practices, Attitudes, and
 Policies
That enable an individual, agency, or
system to effectively serve culturally
diverse communities.
from The Asian Health Coalition of Illinois

Here at Hill Country MHDDC
Consumers are very diverse in their
language and culture.

61% of our Consumers are
Caucasian Americans
Many have German
backgrounds.

Our Consumers are …..

n
1% NativeAmerican

33% Hispanic
1% Asian

3% African
American

1% are “Others”

Consumers Have Many
Different Lifestyles

Lifestyles

They have many different
beliefs.

Can We Communicate?
Think Language first!
 Do we need an interpreter?
 Communicate respectfully.
 Be sensitive to the consumer and the family.
 Consider your dress, tone of voice, eye contact,
location, seating arrangement, privacy, etc.


Is our approach culturally
appropriate?
“What do you call your problem?”
“What name does it have?”
“What do you think caused your problem?”
“Why do you think it started when it did?”
From Arthur Kleinman’s question protocol in“Culture,Illness, and Care:
Clinical Lessons from Anthropologic and Cross Cultural Research”,
Ann.Intern.Med. 1978:Vol.88, pg.251-258

Important Issues to Consider…





Impact of religion.
How are women, men, elders, and children
treated in their culture?
Is there domestic violence?
Ethnic minorities generally underutilize
outpatient services, although African-Americans
are over-represented in inpatient setting.

Diagnosis






Minorities with Bipolar Disorder are often
diagnosed with schizophrenia. (Mukherjee,et al)
African Americans are over diagnosed with
schizophrenia and under diagnosed with mood
disorders. (Bell )
A mental health consumer’s addictions may not
be treated.
The elderly may not be assessed for substance
abuse or alcoholism.

Diagnosis
A person with a primary addiction problem
might not be treated for a co-occurring mental
illness.
 Learning disabilities may not be identified in
individuals with mental illness or substance
abuse.
 A person with mental retardation may not be
treated for mental illness or substance abuse.


Diagnosis
Post Traumatic Stress Disorder is often
undiagnosed in people suffering from
Domestic Abuse or other trauma.
 Children who are witnessing or are
victims of domestic abuse or another
trauma, may be misdiagnosed with
Attention Deficit Hyperactivity Disorder.


Medication Differences





Asians and Hispanics need lower doses of antipsychotics.
African Americans use the same doses of antipsychotics, but lower doses of lithium.
The elderly need lower dosages of medications.
Thus, metabolism of drugs varies with age and
ethnicity and is critical in prescribing
medications.

From “Making Room for Culture in Psychiatry” by Lin, et al.

Pain Tolerance
Men and women tolerate pain differently.
 Cultures tolerate pain differently.
 People with addictions develop a
hypersensitivity to pain.
 In certain cultures, self-inflicted pain is a
part of a religious experience.


Religion





Religious beliefs shape how the world is viewed.
Is illness a punishment? The devil’s work? An
evil spell? Bad karma?
For Hispanics, the curandero is a trusted healer.
For Lakota Sioux, the ritual Vision Quest,
praying and fasting at a holy site is life
changing.

Remember there are as many
differences
Between individuals in the same
culture as there are between
individuals in different cultures!

Two African American
families, one lesbian
and the other, multi-racial.

German Consumers
Suggestions from our Gillespie County MH staff

What generation German?
 Would they feel more comfortable
speaking in German?


A consumer reacting to internal stimuli.

German Consumers
Suggestions from our Gillespie MHC staff in Fredericksburg

They may be resistant to seeking
mental services.
They may be reluctant to take medication.
They may “keep things within the family.”
They are concerned about the stigma.

German Consumers
They may feel it’s a character flaw or a
disgrace.
 They are very concerned about
confidentiality.
 Drinking alcohol is an accepted part of
their culture.
 Teen drinking may be acceptable in their
family.


Hispanic Consumers
from the U.S. Census, 1/23/03 Houston Chronicle

Hispanics are the largest minority group in
the U.S. with 37 million people.
 Texas is approximately 32 percent
Hispanic
 11.5 % African American,
 3.3% Other
 53.1% Anglo


Treatment Issues for Hispanic
Consumers
Do we need an interpreter?
 Is the person Tejano or from Mexico?
What generation Hispanic?
Is the person using a curandero?

Treatment issues for Hispanic
Consumers
Hallucinations are natural in their
religion.
 Hearing the voice of a loved one or having
hallucinations might be an expectations
when celebrating the Day of the Dead.
 Hispanic families are patriarchal.


Hispanic Consumers and
The Day of the Dead
A man is dressed in a skeleton
costume to portray death
in a celebration of
Dia de los Muertos,
The Day of the Dead.
People visit the graves of their
dead relatives to honor them.

Native Americans

Treatment Issues for Native
American Consumers
 Impact of racism,unemployment,and poverty.
 Coping with reservation life and
assimilation in mainstream culture.
 Consider the obesity, diabetes,
hypertension, and alcoholism in adults
and fetal alcohol syndrome in children.
 High use of native healers in the Southwest.

African Americans

African Americans
from the Houston Chronicle, 1/23/03

There are 36.2 million Americans who
identify themselves as “black only.”
 37.7 million identify themselves as “black
and at least one other race.”
 11.5% of Texans are African Americans.


Treatment Issues for African
American
Assess for co-occurring substance use
disorders and alcoholism.
 Address complications of obesity,
hypertension, diabetes,congestive heart
failure, asthma, and cancer.
 Sickle cell anemia is another illness
specific to African Americans.


Treatment Issues for African
Americans
Matriarchy; Mom or grandmother are the
dominant family figures.
 Lack of male role models and intact
families.
 Extended family or the Church may be
supports.


Treatment Issues for African
Americans


There is discrimination within their own
group based on skin color, hair texture,
class, values, etc.

Treatment Issues for Asians

Asians rarely seek help until its very severe.
Asians have extremely low admissions to state hospitals.
Mental illness is considered shameful. It’s hidden.
Is an interpreter needed?

Treatment Issues for Asians
Focus on physical symptoms.
 Asians are sensitive to medication.
 Give ½ the standard dose.
 Asians may use traditional healers and
herbal medicine.
 Asians may “flush” when drinking
alcohol.


Asian Consumers

Acupuncture has been used to treat
pain, schizophrenia, depression, and addictions.

Treatment Issues for Asians
Asian Cultures are patriarchal.
 The males in the family have the authority.
 Asians are more formal and inhibited in
their social behavior.


Older Adults

Treatment Issues for Older
Adults
Are they aware they need help?

Treatment Issues for Older
Adults
Is their mental illness caused by medicine?
 Do their medical problems cause or
complicate their mental illness?
 Is there Elder Abuse?


Gay Men and Lesbian Women
May struggle with homophobia and“being in the
closet” at work and with their families.
Gay people may want marriage, children, partner
benefits, etc., but may endure legal barriers.

Gay and Lesbian Women
Gay people often have specific health
issues related to their sexual practices.
 HIV, AIDS and STD’s are still concerns
with Gay men.
 People may be grieving the death of a
partner or friends who’ve died from AIDS,
or coping with living with AIDS or being
HIV+ themselves.


Treatment Issues for Gay and
Lesbians
Explore childhood abuse issues and
Domestic Violence..
 Assess for substance use and alcoholism.
 Sex enhancing drug use may be common
among some gay men.


Physically Challenged
Can they get to treatment?
Deal with their frustration and depression
Re: their disability.
 Do they need vocational assistance?

Mentally Challenged

Treatment Issues of Mentally
Challenged
They need to have meaningful activity
and purpose in their lives.
 They need to feel acknowledged and
appreciated.
 They need safety, structure, and security.
 Lack of continuity can cause crisis!
 They may need vocational assistance.


Winona Ryder

December 12, 2001,
Winona Ryder shoplifted
$5,560.40 designer items
from Saks Fifth Avenue in
Beverley Hills.

Twice an Academy
Award Nominated
actress

She had the following 8 drugs in
her possession:
Liquid demerol
 Liquid Diazepam
 Vicodin
 Percodan
 Valium
 Morphine sulfate
 Endocet (containing Oxycodone)


Patterns of Drug Use are highly
Regional.
 Drugs,

routes of administration, street
names, patterns of use, and drug
combinations may differ greatly, not
only between individuals from
different cultures, but different parts
of the country or even different parts
of the city.

Drugs of Choice
Native Americans-alcohol
 Asians-gambling, work
 Gay Men-stimulants, amyl nitrate, ecstasy
 “Rich”-prescription drugs, Internet porn
 M.D.’s –Vicodin


Drugs of Choice
Young adults-marijuana, cigarettes
 Geriatrics-alcohol, pills
 Sex Workers-crack cocaine, IV speedballs
 Screen mentally retarded for abuse too!


How Do We Best Serve Our
Consumers?




Examine own stereotypes.
Build trust.
Use People First language!

How do we best serve our
consumers?
Pronounce the person’s name correctly.
 Get an interpreter, if necessary.
 Educate yourself from the consumer, his
family, co-workers, etc.
 Remember differences do matter!



Slide 30

Cultural Competence
Integrating Differences
into Community Services

Objectives
Understand Stigma.
 Understand Culture Competency.
 Learn Culturally competent care for
people with Mental Health, Mental
Retardation and Addictions.


We live in an world
which often separates us.
Racism
 Sexism
 Ageism
 Feminism
 Classism
 Atheism


“Different” people are
“Stigmatized”

Mentally retarded inmates in a sanitorium in Germany

Stigma
Definitions from the U. of Chicago PSR Training Manual

“Stigmas are negative attitudes about a
group that lead to depriving them of
some fair opportunities.”

Stigma is related to…..
Stereotypes
Prejudice
Discrimination

Stereotypes
from The Asian Health Coalition of Illinois

Stereotypes are exaggerated beliefs
or fixed ideas about a person or
group which is held by people and
sustained by selective perception and
selective forgetting.

Prejudice
from The Asian Health Coalition of Illinois

Prejudice is a preconceived idea or
negative attitude formed before the
facts are known and sustained over
generalizations. A bias without
reason, resisting all evidence…

Discrimination
from The Asian Health Coalition of Illinois

Discrimination refers to treatment in
favor or against a person based on
the group to which that person
belongs and not on merit.

Stigmatized People…..
Experience being stereotyped and
are often the object of
discrimination and prejudice.

People are often stigmatized by:













Mental Illness
Mental Retardation
Physical Disability (including blindness, deafness)
Alcoholism /and or Drug Addiction
HIV or AIDS, Cancer or other terminal illnesses
Criminal behavior
Poverty
Alternative Lifestyles/sexual orientation
Wheelchair bound
Gender
Obesity

All our Consumers belong to
stigmatized groups!

Stigmatized People
Consumers and their families
can’t navigate the bureaucracy
even if resources are there.
It’s too frustrating!

Use People First Language
“I am more than my
illness….Don’t call me
“the schizophrenic,
“the addict” or
“the retard.”

As human beings, we have many
similarities…..
But, who we really are, is often
derived from our original family of origin
and our current lifestyle.

The Bottom Line:
People are different, even within
their own culture!
These differences matter when
planning and providing services.

National Mental Health
Association
“For Mental Health consumers, both
access to the services and the effectiveness
of the care they receive are greatly affected
by the degree to which the delivery system
is“culturally competent.”

Some important definitions
Related to Cultural Competency

Culture

from King,et. al

The Office of Special Programs, U.S. Dept. of Education

“The integrated patterns of human
behavior that includes thoughts,
communications, actions, customs,
beliefs,values, and institutions of
racial, ethnic, religious, or social
groups.”

Cultural Sensitivity
An awareness and respect of a
person’s cultural beliefs and
values.
Culhane-Pera, et .al

Cultural Competency
 Skills

(that translate into)
 Behaviors, Practices, Attitudes, and
 Policies
That enable an individual, agency, or
system to effectively serve culturally
diverse communities.
from The Asian Health Coalition of Illinois

Here at Hill Country MHDDC
Consumers are very diverse in their
language and culture.

61% of our Consumers are
Caucasian Americans
Many have German
backgrounds.

Our Consumers are …..

n
1% NativeAmerican

33% Hispanic
1% Asian

3% African
American

1% are “Others”

Consumers Have Many
Different Lifestyles

Lifestyles

They have many different
beliefs.

Can We Communicate?
Think Language first!
 Do we need an interpreter?
 Communicate respectfully.
 Be sensitive to the consumer and the family.
 Consider your dress, tone of voice, eye contact,
location, seating arrangement, privacy, etc.


Is our approach culturally
appropriate?
“What do you call your problem?”
“What name does it have?”
“What do you think caused your problem?”
“Why do you think it started when it did?”
From Arthur Kleinman’s question protocol in“Culture,Illness, and Care:
Clinical Lessons from Anthropologic and Cross Cultural Research”,
Ann.Intern.Med. 1978:Vol.88, pg.251-258

Important Issues to Consider…





Impact of religion.
How are women, men, elders, and children
treated in their culture?
Is there domestic violence?
Ethnic minorities generally underutilize
outpatient services, although African-Americans
are over-represented in inpatient setting.

Diagnosis






Minorities with Bipolar Disorder are often
diagnosed with schizophrenia. (Mukherjee,et al)
African Americans are over diagnosed with
schizophrenia and under diagnosed with mood
disorders. (Bell )
A mental health consumer’s addictions may not
be treated.
The elderly may not be assessed for substance
abuse or alcoholism.

Diagnosis
A person with a primary addiction problem
might not be treated for a co-occurring mental
illness.
 Learning disabilities may not be identified in
individuals with mental illness or substance
abuse.
 A person with mental retardation may not be
treated for mental illness or substance abuse.


Diagnosis
Post Traumatic Stress Disorder is often
undiagnosed in people suffering from
Domestic Abuse or other trauma.
 Children who are witnessing or are
victims of domestic abuse or another
trauma, may be misdiagnosed with
Attention Deficit Hyperactivity Disorder.


Medication Differences





Asians and Hispanics need lower doses of antipsychotics.
African Americans use the same doses of antipsychotics, but lower doses of lithium.
The elderly need lower dosages of medications.
Thus, metabolism of drugs varies with age and
ethnicity and is critical in prescribing
medications.

From “Making Room for Culture in Psychiatry” by Lin, et al.

Pain Tolerance
Men and women tolerate pain differently.
 Cultures tolerate pain differently.
 People with addictions develop a
hypersensitivity to pain.
 In certain cultures, self-inflicted pain is a
part of a religious experience.


Religion





Religious beliefs shape how the world is viewed.
Is illness a punishment? The devil’s work? An
evil spell? Bad karma?
For Hispanics, the curandero is a trusted healer.
For Lakota Sioux, the ritual Vision Quest,
praying and fasting at a holy site is life
changing.

Remember there are as many
differences
Between individuals in the same
culture as there are between
individuals in different cultures!

Two African American
families, one lesbian
and the other, multi-racial.

German Consumers
Suggestions from our Gillespie County MH staff

What generation German?
 Would they feel more comfortable
speaking in German?


A consumer reacting to internal stimuli.

German Consumers
Suggestions from our Gillespie MHC staff in Fredericksburg

They may be resistant to seeking
mental services.
They may be reluctant to take medication.
They may “keep things within the family.”
They are concerned about the stigma.

German Consumers
They may feel it’s a character flaw or a
disgrace.
 They are very concerned about
confidentiality.
 Drinking alcohol is an accepted part of
their culture.
 Teen drinking may be acceptable in their
family.


Hispanic Consumers
from the U.S. Census, 1/23/03 Houston Chronicle

Hispanics are the largest minority group in
the U.S. with 37 million people.
 Texas is approximately 32 percent
Hispanic
 11.5 % African American,
 3.3% Other
 53.1% Anglo


Treatment Issues for Hispanic
Consumers
Do we need an interpreter?
 Is the person Tejano or from Mexico?
What generation Hispanic?
Is the person using a curandero?

Treatment issues for Hispanic
Consumers
Hallucinations are natural in their
religion.
 Hearing the voice of a loved one or having
hallucinations might be an expectations
when celebrating the Day of the Dead.
 Hispanic families are patriarchal.


Hispanic Consumers and
The Day of the Dead
A man is dressed in a skeleton
costume to portray death
in a celebration of
Dia de los Muertos,
The Day of the Dead.
People visit the graves of their
dead relatives to honor them.

Native Americans

Treatment Issues for Native
American Consumers
 Impact of racism,unemployment,and poverty.
 Coping with reservation life and
assimilation in mainstream culture.
 Consider the obesity, diabetes,
hypertension, and alcoholism in adults
and fetal alcohol syndrome in children.
 High use of native healers in the Southwest.

African Americans

African Americans
from the Houston Chronicle, 1/23/03

There are 36.2 million Americans who
identify themselves as “black only.”
 37.7 million identify themselves as “black
and at least one other race.”
 11.5% of Texans are African Americans.


Treatment Issues for African
American
Assess for co-occurring substance use
disorders and alcoholism.
 Address complications of obesity,
hypertension, diabetes,congestive heart
failure, asthma, and cancer.
 Sickle cell anemia is another illness
specific to African Americans.


Treatment Issues for African
Americans
Matriarchy; Mom or grandmother are the
dominant family figures.
 Lack of male role models and intact
families.
 Extended family or the Church may be
supports.


Treatment Issues for African
Americans


There is discrimination within their own
group based on skin color, hair texture,
class, values, etc.

Treatment Issues for Asians

Asians rarely seek help until its very severe.
Asians have extremely low admissions to state hospitals.
Mental illness is considered shameful. It’s hidden.
Is an interpreter needed?

Treatment Issues for Asians
Focus on physical symptoms.
 Asians are sensitive to medication.
 Give ½ the standard dose.
 Asians may use traditional healers and
herbal medicine.
 Asians may “flush” when drinking
alcohol.


Asian Consumers

Acupuncture has been used to treat
pain, schizophrenia, depression, and addictions.

Treatment Issues for Asians
Asian Cultures are patriarchal.
 The males in the family have the authority.
 Asians are more formal and inhibited in
their social behavior.


Older Adults

Treatment Issues for Older
Adults
Are they aware they need help?

Treatment Issues for Older
Adults
Is their mental illness caused by medicine?
 Do their medical problems cause or
complicate their mental illness?
 Is there Elder Abuse?


Gay Men and Lesbian Women
May struggle with homophobia and“being in the
closet” at work and with their families.
Gay people may want marriage, children, partner
benefits, etc., but may endure legal barriers.

Gay and Lesbian Women
Gay people often have specific health
issues related to their sexual practices.
 HIV, AIDS and STD’s are still concerns
with Gay men.
 People may be grieving the death of a
partner or friends who’ve died from AIDS,
or coping with living with AIDS or being
HIV+ themselves.


Treatment Issues for Gay and
Lesbians
Explore childhood abuse issues and
Domestic Violence..
 Assess for substance use and alcoholism.
 Sex enhancing drug use may be common
among some gay men.


Physically Challenged
Can they get to treatment?
Deal with their frustration and depression
Re: their disability.
 Do they need vocational assistance?

Mentally Challenged

Treatment Issues of Mentally
Challenged
They need to have meaningful activity
and purpose in their lives.
 They need to feel acknowledged and
appreciated.
 They need safety, structure, and security.
 Lack of continuity can cause crisis!
 They may need vocational assistance.


Winona Ryder

December 12, 2001,
Winona Ryder shoplifted
$5,560.40 designer items
from Saks Fifth Avenue in
Beverley Hills.

Twice an Academy
Award Nominated
actress

She had the following 8 drugs in
her possession:
Liquid demerol
 Liquid Diazepam
 Vicodin
 Percodan
 Valium
 Morphine sulfate
 Endocet (containing Oxycodone)


Patterns of Drug Use are highly
Regional.
 Drugs,

routes of administration, street
names, patterns of use, and drug
combinations may differ greatly, not
only between individuals from
different cultures, but different parts
of the country or even different parts
of the city.

Drugs of Choice
Native Americans-alcohol
 Asians-gambling, work
 Gay Men-stimulants, amyl nitrate, ecstasy
 “Rich”-prescription drugs, Internet porn
 M.D.’s –Vicodin


Drugs of Choice
Young adults-marijuana, cigarettes
 Geriatrics-alcohol, pills
 Sex Workers-crack cocaine, IV speedballs
 Screen mentally retarded for abuse too!


How Do We Best Serve Our
Consumers?




Examine own stereotypes.
Build trust.
Use People First language!

How do we best serve our
consumers?
Pronounce the person’s name correctly.
 Get an interpreter, if necessary.
 Educate yourself from the consumer, his
family, co-workers, etc.
 Remember differences do matter!



Slide 31

Cultural Competence
Integrating Differences
into Community Services

Objectives
Understand Stigma.
 Understand Culture Competency.
 Learn Culturally competent care for
people with Mental Health, Mental
Retardation and Addictions.


We live in an world
which often separates us.
Racism
 Sexism
 Ageism
 Feminism
 Classism
 Atheism


“Different” people are
“Stigmatized”

Mentally retarded inmates in a sanitorium in Germany

Stigma
Definitions from the U. of Chicago PSR Training Manual

“Stigmas are negative attitudes about a
group that lead to depriving them of
some fair opportunities.”

Stigma is related to…..
Stereotypes
Prejudice
Discrimination

Stereotypes
from The Asian Health Coalition of Illinois

Stereotypes are exaggerated beliefs
or fixed ideas about a person or
group which is held by people and
sustained by selective perception and
selective forgetting.

Prejudice
from The Asian Health Coalition of Illinois

Prejudice is a preconceived idea or
negative attitude formed before the
facts are known and sustained over
generalizations. A bias without
reason, resisting all evidence…

Discrimination
from The Asian Health Coalition of Illinois

Discrimination refers to treatment in
favor or against a person based on
the group to which that person
belongs and not on merit.

Stigmatized People…..
Experience being stereotyped and
are often the object of
discrimination and prejudice.

People are often stigmatized by:













Mental Illness
Mental Retardation
Physical Disability (including blindness, deafness)
Alcoholism /and or Drug Addiction
HIV or AIDS, Cancer or other terminal illnesses
Criminal behavior
Poverty
Alternative Lifestyles/sexual orientation
Wheelchair bound
Gender
Obesity

All our Consumers belong to
stigmatized groups!

Stigmatized People
Consumers and their families
can’t navigate the bureaucracy
even if resources are there.
It’s too frustrating!

Use People First Language
“I am more than my
illness….Don’t call me
“the schizophrenic,
“the addict” or
“the retard.”

As human beings, we have many
similarities…..
But, who we really are, is often
derived from our original family of origin
and our current lifestyle.

The Bottom Line:
People are different, even within
their own culture!
These differences matter when
planning and providing services.

National Mental Health
Association
“For Mental Health consumers, both
access to the services and the effectiveness
of the care they receive are greatly affected
by the degree to which the delivery system
is“culturally competent.”

Some important definitions
Related to Cultural Competency

Culture

from King,et. al

The Office of Special Programs, U.S. Dept. of Education

“The integrated patterns of human
behavior that includes thoughts,
communications, actions, customs,
beliefs,values, and institutions of
racial, ethnic, religious, or social
groups.”

Cultural Sensitivity
An awareness and respect of a
person’s cultural beliefs and
values.
Culhane-Pera, et .al

Cultural Competency
 Skills

(that translate into)
 Behaviors, Practices, Attitudes, and
 Policies
That enable an individual, agency, or
system to effectively serve culturally
diverse communities.
from The Asian Health Coalition of Illinois

Here at Hill Country MHDDC
Consumers are very diverse in their
language and culture.

61% of our Consumers are
Caucasian Americans
Many have German
backgrounds.

Our Consumers are …..

n
1% NativeAmerican

33% Hispanic
1% Asian

3% African
American

1% are “Others”

Consumers Have Many
Different Lifestyles

Lifestyles

They have many different
beliefs.

Can We Communicate?
Think Language first!
 Do we need an interpreter?
 Communicate respectfully.
 Be sensitive to the consumer and the family.
 Consider your dress, tone of voice, eye contact,
location, seating arrangement, privacy, etc.


Is our approach culturally
appropriate?
“What do you call your problem?”
“What name does it have?”
“What do you think caused your problem?”
“Why do you think it started when it did?”
From Arthur Kleinman’s question protocol in“Culture,Illness, and Care:
Clinical Lessons from Anthropologic and Cross Cultural Research”,
Ann.Intern.Med. 1978:Vol.88, pg.251-258

Important Issues to Consider…





Impact of religion.
How are women, men, elders, and children
treated in their culture?
Is there domestic violence?
Ethnic minorities generally underutilize
outpatient services, although African-Americans
are over-represented in inpatient setting.

Diagnosis






Minorities with Bipolar Disorder are often
diagnosed with schizophrenia. (Mukherjee,et al)
African Americans are over diagnosed with
schizophrenia and under diagnosed with mood
disorders. (Bell )
A mental health consumer’s addictions may not
be treated.
The elderly may not be assessed for substance
abuse or alcoholism.

Diagnosis
A person with a primary addiction problem
might not be treated for a co-occurring mental
illness.
 Learning disabilities may not be identified in
individuals with mental illness or substance
abuse.
 A person with mental retardation may not be
treated for mental illness or substance abuse.


Diagnosis
Post Traumatic Stress Disorder is often
undiagnosed in people suffering from
Domestic Abuse or other trauma.
 Children who are witnessing or are
victims of domestic abuse or another
trauma, may be misdiagnosed with
Attention Deficit Hyperactivity Disorder.


Medication Differences





Asians and Hispanics need lower doses of antipsychotics.
African Americans use the same doses of antipsychotics, but lower doses of lithium.
The elderly need lower dosages of medications.
Thus, metabolism of drugs varies with age and
ethnicity and is critical in prescribing
medications.

From “Making Room for Culture in Psychiatry” by Lin, et al.

Pain Tolerance
Men and women tolerate pain differently.
 Cultures tolerate pain differently.
 People with addictions develop a
hypersensitivity to pain.
 In certain cultures, self-inflicted pain is a
part of a religious experience.


Religion





Religious beliefs shape how the world is viewed.
Is illness a punishment? The devil’s work? An
evil spell? Bad karma?
For Hispanics, the curandero is a trusted healer.
For Lakota Sioux, the ritual Vision Quest,
praying and fasting at a holy site is life
changing.

Remember there are as many
differences
Between individuals in the same
culture as there are between
individuals in different cultures!

Two African American
families, one lesbian
and the other, multi-racial.

German Consumers
Suggestions from our Gillespie County MH staff

What generation German?
 Would they feel more comfortable
speaking in German?


A consumer reacting to internal stimuli.

German Consumers
Suggestions from our Gillespie MHC staff in Fredericksburg

They may be resistant to seeking
mental services.
They may be reluctant to take medication.
They may “keep things within the family.”
They are concerned about the stigma.

German Consumers
They may feel it’s a character flaw or a
disgrace.
 They are very concerned about
confidentiality.
 Drinking alcohol is an accepted part of
their culture.
 Teen drinking may be acceptable in their
family.


Hispanic Consumers
from the U.S. Census, 1/23/03 Houston Chronicle

Hispanics are the largest minority group in
the U.S. with 37 million people.
 Texas is approximately 32 percent
Hispanic
 11.5 % African American,
 3.3% Other
 53.1% Anglo


Treatment Issues for Hispanic
Consumers
Do we need an interpreter?
 Is the person Tejano or from Mexico?
What generation Hispanic?
Is the person using a curandero?

Treatment issues for Hispanic
Consumers
Hallucinations are natural in their
religion.
 Hearing the voice of a loved one or having
hallucinations might be an expectations
when celebrating the Day of the Dead.
 Hispanic families are patriarchal.


Hispanic Consumers and
The Day of the Dead
A man is dressed in a skeleton
costume to portray death
in a celebration of
Dia de los Muertos,
The Day of the Dead.
People visit the graves of their
dead relatives to honor them.

Native Americans

Treatment Issues for Native
American Consumers
 Impact of racism,unemployment,and poverty.
 Coping with reservation life and
assimilation in mainstream culture.
 Consider the obesity, diabetes,
hypertension, and alcoholism in adults
and fetal alcohol syndrome in children.
 High use of native healers in the Southwest.

African Americans

African Americans
from the Houston Chronicle, 1/23/03

There are 36.2 million Americans who
identify themselves as “black only.”
 37.7 million identify themselves as “black
and at least one other race.”
 11.5% of Texans are African Americans.


Treatment Issues for African
American
Assess for co-occurring substance use
disorders and alcoholism.
 Address complications of obesity,
hypertension, diabetes,congestive heart
failure, asthma, and cancer.
 Sickle cell anemia is another illness
specific to African Americans.


Treatment Issues for African
Americans
Matriarchy; Mom or grandmother are the
dominant family figures.
 Lack of male role models and intact
families.
 Extended family or the Church may be
supports.


Treatment Issues for African
Americans


There is discrimination within their own
group based on skin color, hair texture,
class, values, etc.

Treatment Issues for Asians

Asians rarely seek help until its very severe.
Asians have extremely low admissions to state hospitals.
Mental illness is considered shameful. It’s hidden.
Is an interpreter needed?

Treatment Issues for Asians
Focus on physical symptoms.
 Asians are sensitive to medication.
 Give ½ the standard dose.
 Asians may use traditional healers and
herbal medicine.
 Asians may “flush” when drinking
alcohol.


Asian Consumers

Acupuncture has been used to treat
pain, schizophrenia, depression, and addictions.

Treatment Issues for Asians
Asian Cultures are patriarchal.
 The males in the family have the authority.
 Asians are more formal and inhibited in
their social behavior.


Older Adults

Treatment Issues for Older
Adults
Are they aware they need help?

Treatment Issues for Older
Adults
Is their mental illness caused by medicine?
 Do their medical problems cause or
complicate their mental illness?
 Is there Elder Abuse?


Gay Men and Lesbian Women
May struggle with homophobia and“being in the
closet” at work and with their families.
Gay people may want marriage, children, partner
benefits, etc., but may endure legal barriers.

Gay and Lesbian Women
Gay people often have specific health
issues related to their sexual practices.
 HIV, AIDS and STD’s are still concerns
with Gay men.
 People may be grieving the death of a
partner or friends who’ve died from AIDS,
or coping with living with AIDS or being
HIV+ themselves.


Treatment Issues for Gay and
Lesbians
Explore childhood abuse issues and
Domestic Violence..
 Assess for substance use and alcoholism.
 Sex enhancing drug use may be common
among some gay men.


Physically Challenged
Can they get to treatment?
Deal with their frustration and depression
Re: their disability.
 Do they need vocational assistance?

Mentally Challenged

Treatment Issues of Mentally
Challenged
They need to have meaningful activity
and purpose in their lives.
 They need to feel acknowledged and
appreciated.
 They need safety, structure, and security.
 Lack of continuity can cause crisis!
 They may need vocational assistance.


Winona Ryder

December 12, 2001,
Winona Ryder shoplifted
$5,560.40 designer items
from Saks Fifth Avenue in
Beverley Hills.

Twice an Academy
Award Nominated
actress

She had the following 8 drugs in
her possession:
Liquid demerol
 Liquid Diazepam
 Vicodin
 Percodan
 Valium
 Morphine sulfate
 Endocet (containing Oxycodone)


Patterns of Drug Use are highly
Regional.
 Drugs,

routes of administration, street
names, patterns of use, and drug
combinations may differ greatly, not
only between individuals from
different cultures, but different parts
of the country or even different parts
of the city.

Drugs of Choice
Native Americans-alcohol
 Asians-gambling, work
 Gay Men-stimulants, amyl nitrate, ecstasy
 “Rich”-prescription drugs, Internet porn
 M.D.’s –Vicodin


Drugs of Choice
Young adults-marijuana, cigarettes
 Geriatrics-alcohol, pills
 Sex Workers-crack cocaine, IV speedballs
 Screen mentally retarded for abuse too!


How Do We Best Serve Our
Consumers?




Examine own stereotypes.
Build trust.
Use People First language!

How do we best serve our
consumers?
Pronounce the person’s name correctly.
 Get an interpreter, if necessary.
 Educate yourself from the consumer, his
family, co-workers, etc.
 Remember differences do matter!



Slide 32

Cultural Competence
Integrating Differences
into Community Services

Objectives
Understand Stigma.
 Understand Culture Competency.
 Learn Culturally competent care for
people with Mental Health, Mental
Retardation and Addictions.


We live in an world
which often separates us.
Racism
 Sexism
 Ageism
 Feminism
 Classism
 Atheism


“Different” people are
“Stigmatized”

Mentally retarded inmates in a sanitorium in Germany

Stigma
Definitions from the U. of Chicago PSR Training Manual

“Stigmas are negative attitudes about a
group that lead to depriving them of
some fair opportunities.”

Stigma is related to…..
Stereotypes
Prejudice
Discrimination

Stereotypes
from The Asian Health Coalition of Illinois

Stereotypes are exaggerated beliefs
or fixed ideas about a person or
group which is held by people and
sustained by selective perception and
selective forgetting.

Prejudice
from The Asian Health Coalition of Illinois

Prejudice is a preconceived idea or
negative attitude formed before the
facts are known and sustained over
generalizations. A bias without
reason, resisting all evidence…

Discrimination
from The Asian Health Coalition of Illinois

Discrimination refers to treatment in
favor or against a person based on
the group to which that person
belongs and not on merit.

Stigmatized People…..
Experience being stereotyped and
are often the object of
discrimination and prejudice.

People are often stigmatized by:













Mental Illness
Mental Retardation
Physical Disability (including blindness, deafness)
Alcoholism /and or Drug Addiction
HIV or AIDS, Cancer or other terminal illnesses
Criminal behavior
Poverty
Alternative Lifestyles/sexual orientation
Wheelchair bound
Gender
Obesity

All our Consumers belong to
stigmatized groups!

Stigmatized People
Consumers and their families
can’t navigate the bureaucracy
even if resources are there.
It’s too frustrating!

Use People First Language
“I am more than my
illness….Don’t call me
“the schizophrenic,
“the addict” or
“the retard.”

As human beings, we have many
similarities…..
But, who we really are, is often
derived from our original family of origin
and our current lifestyle.

The Bottom Line:
People are different, even within
their own culture!
These differences matter when
planning and providing services.

National Mental Health
Association
“For Mental Health consumers, both
access to the services and the effectiveness
of the care they receive are greatly affected
by the degree to which the delivery system
is“culturally competent.”

Some important definitions
Related to Cultural Competency

Culture

from King,et. al

The Office of Special Programs, U.S. Dept. of Education

“The integrated patterns of human
behavior that includes thoughts,
communications, actions, customs,
beliefs,values, and institutions of
racial, ethnic, religious, or social
groups.”

Cultural Sensitivity
An awareness and respect of a
person’s cultural beliefs and
values.
Culhane-Pera, et .al

Cultural Competency
 Skills

(that translate into)
 Behaviors, Practices, Attitudes, and
 Policies
That enable an individual, agency, or
system to effectively serve culturally
diverse communities.
from The Asian Health Coalition of Illinois

Here at Hill Country MHDDC
Consumers are very diverse in their
language and culture.

61% of our Consumers are
Caucasian Americans
Many have German
backgrounds.

Our Consumers are …..

n
1% NativeAmerican

33% Hispanic
1% Asian

3% African
American

1% are “Others”

Consumers Have Many
Different Lifestyles

Lifestyles

They have many different
beliefs.

Can We Communicate?
Think Language first!
 Do we need an interpreter?
 Communicate respectfully.
 Be sensitive to the consumer and the family.
 Consider your dress, tone of voice, eye contact,
location, seating arrangement, privacy, etc.


Is our approach culturally
appropriate?
“What do you call your problem?”
“What name does it have?”
“What do you think caused your problem?”
“Why do you think it started when it did?”
From Arthur Kleinman’s question protocol in“Culture,Illness, and Care:
Clinical Lessons from Anthropologic and Cross Cultural Research”,
Ann.Intern.Med. 1978:Vol.88, pg.251-258

Important Issues to Consider…





Impact of religion.
How are women, men, elders, and children
treated in their culture?
Is there domestic violence?
Ethnic minorities generally underutilize
outpatient services, although African-Americans
are over-represented in inpatient setting.

Diagnosis






Minorities with Bipolar Disorder are often
diagnosed with schizophrenia. (Mukherjee,et al)
African Americans are over diagnosed with
schizophrenia and under diagnosed with mood
disorders. (Bell )
A mental health consumer’s addictions may not
be treated.
The elderly may not be assessed for substance
abuse or alcoholism.

Diagnosis
A person with a primary addiction problem
might not be treated for a co-occurring mental
illness.
 Learning disabilities may not be identified in
individuals with mental illness or substance
abuse.
 A person with mental retardation may not be
treated for mental illness or substance abuse.


Diagnosis
Post Traumatic Stress Disorder is often
undiagnosed in people suffering from
Domestic Abuse or other trauma.
 Children who are witnessing or are
victims of domestic abuse or another
trauma, may be misdiagnosed with
Attention Deficit Hyperactivity Disorder.


Medication Differences





Asians and Hispanics need lower doses of antipsychotics.
African Americans use the same doses of antipsychotics, but lower doses of lithium.
The elderly need lower dosages of medications.
Thus, metabolism of drugs varies with age and
ethnicity and is critical in prescribing
medications.

From “Making Room for Culture in Psychiatry” by Lin, et al.

Pain Tolerance
Men and women tolerate pain differently.
 Cultures tolerate pain differently.
 People with addictions develop a
hypersensitivity to pain.
 In certain cultures, self-inflicted pain is a
part of a religious experience.


Religion





Religious beliefs shape how the world is viewed.
Is illness a punishment? The devil’s work? An
evil spell? Bad karma?
For Hispanics, the curandero is a trusted healer.
For Lakota Sioux, the ritual Vision Quest,
praying and fasting at a holy site is life
changing.

Remember there are as many
differences
Between individuals in the same
culture as there are between
individuals in different cultures!

Two African American
families, one lesbian
and the other, multi-racial.

German Consumers
Suggestions from our Gillespie County MH staff

What generation German?
 Would they feel more comfortable
speaking in German?


A consumer reacting to internal stimuli.

German Consumers
Suggestions from our Gillespie MHC staff in Fredericksburg

They may be resistant to seeking
mental services.
They may be reluctant to take medication.
They may “keep things within the family.”
They are concerned about the stigma.

German Consumers
They may feel it’s a character flaw or a
disgrace.
 They are very concerned about
confidentiality.
 Drinking alcohol is an accepted part of
their culture.
 Teen drinking may be acceptable in their
family.


Hispanic Consumers
from the U.S. Census, 1/23/03 Houston Chronicle

Hispanics are the largest minority group in
the U.S. with 37 million people.
 Texas is approximately 32 percent
Hispanic
 11.5 % African American,
 3.3% Other
 53.1% Anglo


Treatment Issues for Hispanic
Consumers
Do we need an interpreter?
 Is the person Tejano or from Mexico?
What generation Hispanic?
Is the person using a curandero?

Treatment issues for Hispanic
Consumers
Hallucinations are natural in their
religion.
 Hearing the voice of a loved one or having
hallucinations might be an expectations
when celebrating the Day of the Dead.
 Hispanic families are patriarchal.


Hispanic Consumers and
The Day of the Dead
A man is dressed in a skeleton
costume to portray death
in a celebration of
Dia de los Muertos,
The Day of the Dead.
People visit the graves of their
dead relatives to honor them.

Native Americans

Treatment Issues for Native
American Consumers
 Impact of racism,unemployment,and poverty.
 Coping with reservation life and
assimilation in mainstream culture.
 Consider the obesity, diabetes,
hypertension, and alcoholism in adults
and fetal alcohol syndrome in children.
 High use of native healers in the Southwest.

African Americans

African Americans
from the Houston Chronicle, 1/23/03

There are 36.2 million Americans who
identify themselves as “black only.”
 37.7 million identify themselves as “black
and at least one other race.”
 11.5% of Texans are African Americans.


Treatment Issues for African
American
Assess for co-occurring substance use
disorders and alcoholism.
 Address complications of obesity,
hypertension, diabetes,congestive heart
failure, asthma, and cancer.
 Sickle cell anemia is another illness
specific to African Americans.


Treatment Issues for African
Americans
Matriarchy; Mom or grandmother are the
dominant family figures.
 Lack of male role models and intact
families.
 Extended family or the Church may be
supports.


Treatment Issues for African
Americans


There is discrimination within their own
group based on skin color, hair texture,
class, values, etc.

Treatment Issues for Asians

Asians rarely seek help until its very severe.
Asians have extremely low admissions to state hospitals.
Mental illness is considered shameful. It’s hidden.
Is an interpreter needed?

Treatment Issues for Asians
Focus on physical symptoms.
 Asians are sensitive to medication.
 Give ½ the standard dose.
 Asians may use traditional healers and
herbal medicine.
 Asians may “flush” when drinking
alcohol.


Asian Consumers

Acupuncture has been used to treat
pain, schizophrenia, depression, and addictions.

Treatment Issues for Asians
Asian Cultures are patriarchal.
 The males in the family have the authority.
 Asians are more formal and inhibited in
their social behavior.


Older Adults

Treatment Issues for Older
Adults
Are they aware they need help?

Treatment Issues for Older
Adults
Is their mental illness caused by medicine?
 Do their medical problems cause or
complicate their mental illness?
 Is there Elder Abuse?


Gay Men and Lesbian Women
May struggle with homophobia and“being in the
closet” at work and with their families.
Gay people may want marriage, children, partner
benefits, etc., but may endure legal barriers.

Gay and Lesbian Women
Gay people often have specific health
issues related to their sexual practices.
 HIV, AIDS and STD’s are still concerns
with Gay men.
 People may be grieving the death of a
partner or friends who’ve died from AIDS,
or coping with living with AIDS or being
HIV+ themselves.


Treatment Issues for Gay and
Lesbians
Explore childhood abuse issues and
Domestic Violence..
 Assess for substance use and alcoholism.
 Sex enhancing drug use may be common
among some gay men.


Physically Challenged
Can they get to treatment?
Deal with their frustration and depression
Re: their disability.
 Do they need vocational assistance?

Mentally Challenged

Treatment Issues of Mentally
Challenged
They need to have meaningful activity
and purpose in their lives.
 They need to feel acknowledged and
appreciated.
 They need safety, structure, and security.
 Lack of continuity can cause crisis!
 They may need vocational assistance.


Winona Ryder

December 12, 2001,
Winona Ryder shoplifted
$5,560.40 designer items
from Saks Fifth Avenue in
Beverley Hills.

Twice an Academy
Award Nominated
actress

She had the following 8 drugs in
her possession:
Liquid demerol
 Liquid Diazepam
 Vicodin
 Percodan
 Valium
 Morphine sulfate
 Endocet (containing Oxycodone)


Patterns of Drug Use are highly
Regional.
 Drugs,

routes of administration, street
names, patterns of use, and drug
combinations may differ greatly, not
only between individuals from
different cultures, but different parts
of the country or even different parts
of the city.

Drugs of Choice
Native Americans-alcohol
 Asians-gambling, work
 Gay Men-stimulants, amyl nitrate, ecstasy
 “Rich”-prescription drugs, Internet porn
 M.D.’s –Vicodin


Drugs of Choice
Young adults-marijuana, cigarettes
 Geriatrics-alcohol, pills
 Sex Workers-crack cocaine, IV speedballs
 Screen mentally retarded for abuse too!


How Do We Best Serve Our
Consumers?




Examine own stereotypes.
Build trust.
Use People First language!

How do we best serve our
consumers?
Pronounce the person’s name correctly.
 Get an interpreter, if necessary.
 Educate yourself from the consumer, his
family, co-workers, etc.
 Remember differences do matter!



Slide 33

Cultural Competence
Integrating Differences
into Community Services

Objectives
Understand Stigma.
 Understand Culture Competency.
 Learn Culturally competent care for
people with Mental Health, Mental
Retardation and Addictions.


We live in an world
which often separates us.
Racism
 Sexism
 Ageism
 Feminism
 Classism
 Atheism


“Different” people are
“Stigmatized”

Mentally retarded inmates in a sanitorium in Germany

Stigma
Definitions from the U. of Chicago PSR Training Manual

“Stigmas are negative attitudes about a
group that lead to depriving them of
some fair opportunities.”

Stigma is related to…..
Stereotypes
Prejudice
Discrimination

Stereotypes
from The Asian Health Coalition of Illinois

Stereotypes are exaggerated beliefs
or fixed ideas about a person or
group which is held by people and
sustained by selective perception and
selective forgetting.

Prejudice
from The Asian Health Coalition of Illinois

Prejudice is a preconceived idea or
negative attitude formed before the
facts are known and sustained over
generalizations. A bias without
reason, resisting all evidence…

Discrimination
from The Asian Health Coalition of Illinois

Discrimination refers to treatment in
favor or against a person based on
the group to which that person
belongs and not on merit.

Stigmatized People…..
Experience being stereotyped and
are often the object of
discrimination and prejudice.

People are often stigmatized by:













Mental Illness
Mental Retardation
Physical Disability (including blindness, deafness)
Alcoholism /and or Drug Addiction
HIV or AIDS, Cancer or other terminal illnesses
Criminal behavior
Poverty
Alternative Lifestyles/sexual orientation
Wheelchair bound
Gender
Obesity

All our Consumers belong to
stigmatized groups!

Stigmatized People
Consumers and their families
can’t navigate the bureaucracy
even if resources are there.
It’s too frustrating!

Use People First Language
“I am more than my
illness….Don’t call me
“the schizophrenic,
“the addict” or
“the retard.”

As human beings, we have many
similarities…..
But, who we really are, is often
derived from our original family of origin
and our current lifestyle.

The Bottom Line:
People are different, even within
their own culture!
These differences matter when
planning and providing services.

National Mental Health
Association
“For Mental Health consumers, both
access to the services and the effectiveness
of the care they receive are greatly affected
by the degree to which the delivery system
is“culturally competent.”

Some important definitions
Related to Cultural Competency

Culture

from King,et. al

The Office of Special Programs, U.S. Dept. of Education

“The integrated patterns of human
behavior that includes thoughts,
communications, actions, customs,
beliefs,values, and institutions of
racial, ethnic, religious, or social
groups.”

Cultural Sensitivity
An awareness and respect of a
person’s cultural beliefs and
values.
Culhane-Pera, et .al

Cultural Competency
 Skills

(that translate into)
 Behaviors, Practices, Attitudes, and
 Policies
That enable an individual, agency, or
system to effectively serve culturally
diverse communities.
from The Asian Health Coalition of Illinois

Here at Hill Country MHDDC
Consumers are very diverse in their
language and culture.

61% of our Consumers are
Caucasian Americans
Many have German
backgrounds.

Our Consumers are …..

n
1% NativeAmerican

33% Hispanic
1% Asian

3% African
American

1% are “Others”

Consumers Have Many
Different Lifestyles

Lifestyles

They have many different
beliefs.

Can We Communicate?
Think Language first!
 Do we need an interpreter?
 Communicate respectfully.
 Be sensitive to the consumer and the family.
 Consider your dress, tone of voice, eye contact,
location, seating arrangement, privacy, etc.


Is our approach culturally
appropriate?
“What do you call your problem?”
“What name does it have?”
“What do you think caused your problem?”
“Why do you think it started when it did?”
From Arthur Kleinman’s question protocol in“Culture,Illness, and Care:
Clinical Lessons from Anthropologic and Cross Cultural Research”,
Ann.Intern.Med. 1978:Vol.88, pg.251-258

Important Issues to Consider…





Impact of religion.
How are women, men, elders, and children
treated in their culture?
Is there domestic violence?
Ethnic minorities generally underutilize
outpatient services, although African-Americans
are over-represented in inpatient setting.

Diagnosis






Minorities with Bipolar Disorder are often
diagnosed with schizophrenia. (Mukherjee,et al)
African Americans are over diagnosed with
schizophrenia and under diagnosed with mood
disorders. (Bell )
A mental health consumer’s addictions may not
be treated.
The elderly may not be assessed for substance
abuse or alcoholism.

Diagnosis
A person with a primary addiction problem
might not be treated for a co-occurring mental
illness.
 Learning disabilities may not be identified in
individuals with mental illness or substance
abuse.
 A person with mental retardation may not be
treated for mental illness or substance abuse.


Diagnosis
Post Traumatic Stress Disorder is often
undiagnosed in people suffering from
Domestic Abuse or other trauma.
 Children who are witnessing or are
victims of domestic abuse or another
trauma, may be misdiagnosed with
Attention Deficit Hyperactivity Disorder.


Medication Differences





Asians and Hispanics need lower doses of antipsychotics.
African Americans use the same doses of antipsychotics, but lower doses of lithium.
The elderly need lower dosages of medications.
Thus, metabolism of drugs varies with age and
ethnicity and is critical in prescribing
medications.

From “Making Room for Culture in Psychiatry” by Lin, et al.

Pain Tolerance
Men and women tolerate pain differently.
 Cultures tolerate pain differently.
 People with addictions develop a
hypersensitivity to pain.
 In certain cultures, self-inflicted pain is a
part of a religious experience.


Religion





Religious beliefs shape how the world is viewed.
Is illness a punishment? The devil’s work? An
evil spell? Bad karma?
For Hispanics, the curandero is a trusted healer.
For Lakota Sioux, the ritual Vision Quest,
praying and fasting at a holy site is life
changing.

Remember there are as many
differences
Between individuals in the same
culture as there are between
individuals in different cultures!

Two African American
families, one lesbian
and the other, multi-racial.

German Consumers
Suggestions from our Gillespie County MH staff

What generation German?
 Would they feel more comfortable
speaking in German?


A consumer reacting to internal stimuli.

German Consumers
Suggestions from our Gillespie MHC staff in Fredericksburg

They may be resistant to seeking
mental services.
They may be reluctant to take medication.
They may “keep things within the family.”
They are concerned about the stigma.

German Consumers
They may feel it’s a character flaw or a
disgrace.
 They are very concerned about
confidentiality.
 Drinking alcohol is an accepted part of
their culture.
 Teen drinking may be acceptable in their
family.


Hispanic Consumers
from the U.S. Census, 1/23/03 Houston Chronicle

Hispanics are the largest minority group in
the U.S. with 37 million people.
 Texas is approximately 32 percent
Hispanic
 11.5 % African American,
 3.3% Other
 53.1% Anglo


Treatment Issues for Hispanic
Consumers
Do we need an interpreter?
 Is the person Tejano or from Mexico?
What generation Hispanic?
Is the person using a curandero?

Treatment issues for Hispanic
Consumers
Hallucinations are natural in their
religion.
 Hearing the voice of a loved one or having
hallucinations might be an expectations
when celebrating the Day of the Dead.
 Hispanic families are patriarchal.


Hispanic Consumers and
The Day of the Dead
A man is dressed in a skeleton
costume to portray death
in a celebration of
Dia de los Muertos,
The Day of the Dead.
People visit the graves of their
dead relatives to honor them.

Native Americans

Treatment Issues for Native
American Consumers
 Impact of racism,unemployment,and poverty.
 Coping with reservation life and
assimilation in mainstream culture.
 Consider the obesity, diabetes,
hypertension, and alcoholism in adults
and fetal alcohol syndrome in children.
 High use of native healers in the Southwest.

African Americans

African Americans
from the Houston Chronicle, 1/23/03

There are 36.2 million Americans who
identify themselves as “black only.”
 37.7 million identify themselves as “black
and at least one other race.”
 11.5% of Texans are African Americans.


Treatment Issues for African
American
Assess for co-occurring substance use
disorders and alcoholism.
 Address complications of obesity,
hypertension, diabetes,congestive heart
failure, asthma, and cancer.
 Sickle cell anemia is another illness
specific to African Americans.


Treatment Issues for African
Americans
Matriarchy; Mom or grandmother are the
dominant family figures.
 Lack of male role models and intact
families.
 Extended family or the Church may be
supports.


Treatment Issues for African
Americans


There is discrimination within their own
group based on skin color, hair texture,
class, values, etc.

Treatment Issues for Asians

Asians rarely seek help until its very severe.
Asians have extremely low admissions to state hospitals.
Mental illness is considered shameful. It’s hidden.
Is an interpreter needed?

Treatment Issues for Asians
Focus on physical symptoms.
 Asians are sensitive to medication.
 Give ½ the standard dose.
 Asians may use traditional healers and
herbal medicine.
 Asians may “flush” when drinking
alcohol.


Asian Consumers

Acupuncture has been used to treat
pain, schizophrenia, depression, and addictions.

Treatment Issues for Asians
Asian Cultures are patriarchal.
 The males in the family have the authority.
 Asians are more formal and inhibited in
their social behavior.


Older Adults

Treatment Issues for Older
Adults
Are they aware they need help?

Treatment Issues for Older
Adults
Is their mental illness caused by medicine?
 Do their medical problems cause or
complicate their mental illness?
 Is there Elder Abuse?


Gay Men and Lesbian Women
May struggle with homophobia and“being in the
closet” at work and with their families.
Gay people may want marriage, children, partner
benefits, etc., but may endure legal barriers.

Gay and Lesbian Women
Gay people often have specific health
issues related to their sexual practices.
 HIV, AIDS and STD’s are still concerns
with Gay men.
 People may be grieving the death of a
partner or friends who’ve died from AIDS,
or coping with living with AIDS or being
HIV+ themselves.


Treatment Issues for Gay and
Lesbians
Explore childhood abuse issues and
Domestic Violence..
 Assess for substance use and alcoholism.
 Sex enhancing drug use may be common
among some gay men.


Physically Challenged
Can they get to treatment?
Deal with their frustration and depression
Re: their disability.
 Do they need vocational assistance?

Mentally Challenged

Treatment Issues of Mentally
Challenged
They need to have meaningful activity
and purpose in their lives.
 They need to feel acknowledged and
appreciated.
 They need safety, structure, and security.
 Lack of continuity can cause crisis!
 They may need vocational assistance.


Winona Ryder

December 12, 2001,
Winona Ryder shoplifted
$5,560.40 designer items
from Saks Fifth Avenue in
Beverley Hills.

Twice an Academy
Award Nominated
actress

She had the following 8 drugs in
her possession:
Liquid demerol
 Liquid Diazepam
 Vicodin
 Percodan
 Valium
 Morphine sulfate
 Endocet (containing Oxycodone)


Patterns of Drug Use are highly
Regional.
 Drugs,

routes of administration, street
names, patterns of use, and drug
combinations may differ greatly, not
only between individuals from
different cultures, but different parts
of the country or even different parts
of the city.

Drugs of Choice
Native Americans-alcohol
 Asians-gambling, work
 Gay Men-stimulants, amyl nitrate, ecstasy
 “Rich”-prescription drugs, Internet porn
 M.D.’s –Vicodin


Drugs of Choice
Young adults-marijuana, cigarettes
 Geriatrics-alcohol, pills
 Sex Workers-crack cocaine, IV speedballs
 Screen mentally retarded for abuse too!


How Do We Best Serve Our
Consumers?




Examine own stereotypes.
Build trust.
Use People First language!

How do we best serve our
consumers?
Pronounce the person’s name correctly.
 Get an interpreter, if necessary.
 Educate yourself from the consumer, his
family, co-workers, etc.
 Remember differences do matter!



Slide 34

Cultural Competence
Integrating Differences
into Community Services

Objectives
Understand Stigma.
 Understand Culture Competency.
 Learn Culturally competent care for
people with Mental Health, Mental
Retardation and Addictions.


We live in an world
which often separates us.
Racism
 Sexism
 Ageism
 Feminism
 Classism
 Atheism


“Different” people are
“Stigmatized”

Mentally retarded inmates in a sanitorium in Germany

Stigma
Definitions from the U. of Chicago PSR Training Manual

“Stigmas are negative attitudes about a
group that lead to depriving them of
some fair opportunities.”

Stigma is related to…..
Stereotypes
Prejudice
Discrimination

Stereotypes
from The Asian Health Coalition of Illinois

Stereotypes are exaggerated beliefs
or fixed ideas about a person or
group which is held by people and
sustained by selective perception and
selective forgetting.

Prejudice
from The Asian Health Coalition of Illinois

Prejudice is a preconceived idea or
negative attitude formed before the
facts are known and sustained over
generalizations. A bias without
reason, resisting all evidence…

Discrimination
from The Asian Health Coalition of Illinois

Discrimination refers to treatment in
favor or against a person based on
the group to which that person
belongs and not on merit.

Stigmatized People…..
Experience being stereotyped and
are often the object of
discrimination and prejudice.

People are often stigmatized by:













Mental Illness
Mental Retardation
Physical Disability (including blindness, deafness)
Alcoholism /and or Drug Addiction
HIV or AIDS, Cancer or other terminal illnesses
Criminal behavior
Poverty
Alternative Lifestyles/sexual orientation
Wheelchair bound
Gender
Obesity

All our Consumers belong to
stigmatized groups!

Stigmatized People
Consumers and their families
can’t navigate the bureaucracy
even if resources are there.
It’s too frustrating!

Use People First Language
“I am more than my
illness….Don’t call me
“the schizophrenic,
“the addict” or
“the retard.”

As human beings, we have many
similarities…..
But, who we really are, is often
derived from our original family of origin
and our current lifestyle.

The Bottom Line:
People are different, even within
their own culture!
These differences matter when
planning and providing services.

National Mental Health
Association
“For Mental Health consumers, both
access to the services and the effectiveness
of the care they receive are greatly affected
by the degree to which the delivery system
is“culturally competent.”

Some important definitions
Related to Cultural Competency

Culture

from King,et. al

The Office of Special Programs, U.S. Dept. of Education

“The integrated patterns of human
behavior that includes thoughts,
communications, actions, customs,
beliefs,values, and institutions of
racial, ethnic, religious, or social
groups.”

Cultural Sensitivity
An awareness and respect of a
person’s cultural beliefs and
values.
Culhane-Pera, et .al

Cultural Competency
 Skills

(that translate into)
 Behaviors, Practices, Attitudes, and
 Policies
That enable an individual, agency, or
system to effectively serve culturally
diverse communities.
from The Asian Health Coalition of Illinois

Here at Hill Country MHDDC
Consumers are very diverse in their
language and culture.

61% of our Consumers are
Caucasian Americans
Many have German
backgrounds.

Our Consumers are …..

n
1% NativeAmerican

33% Hispanic
1% Asian

3% African
American

1% are “Others”

Consumers Have Many
Different Lifestyles

Lifestyles

They have many different
beliefs.

Can We Communicate?
Think Language first!
 Do we need an interpreter?
 Communicate respectfully.
 Be sensitive to the consumer and the family.
 Consider your dress, tone of voice, eye contact,
location, seating arrangement, privacy, etc.


Is our approach culturally
appropriate?
“What do you call your problem?”
“What name does it have?”
“What do you think caused your problem?”
“Why do you think it started when it did?”
From Arthur Kleinman’s question protocol in“Culture,Illness, and Care:
Clinical Lessons from Anthropologic and Cross Cultural Research”,
Ann.Intern.Med. 1978:Vol.88, pg.251-258

Important Issues to Consider…





Impact of religion.
How are women, men, elders, and children
treated in their culture?
Is there domestic violence?
Ethnic minorities generally underutilize
outpatient services, although African-Americans
are over-represented in inpatient setting.

Diagnosis






Minorities with Bipolar Disorder are often
diagnosed with schizophrenia. (Mukherjee,et al)
African Americans are over diagnosed with
schizophrenia and under diagnosed with mood
disorders. (Bell )
A mental health consumer’s addictions may not
be treated.
The elderly may not be assessed for substance
abuse or alcoholism.

Diagnosis
A person with a primary addiction problem
might not be treated for a co-occurring mental
illness.
 Learning disabilities may not be identified in
individuals with mental illness or substance
abuse.
 A person with mental retardation may not be
treated for mental illness or substance abuse.


Diagnosis
Post Traumatic Stress Disorder is often
undiagnosed in people suffering from
Domestic Abuse or other trauma.
 Children who are witnessing or are
victims of domestic abuse or another
trauma, may be misdiagnosed with
Attention Deficit Hyperactivity Disorder.


Medication Differences





Asians and Hispanics need lower doses of antipsychotics.
African Americans use the same doses of antipsychotics, but lower doses of lithium.
The elderly need lower dosages of medications.
Thus, metabolism of drugs varies with age and
ethnicity and is critical in prescribing
medications.

From “Making Room for Culture in Psychiatry” by Lin, et al.

Pain Tolerance
Men and women tolerate pain differently.
 Cultures tolerate pain differently.
 People with addictions develop a
hypersensitivity to pain.
 In certain cultures, self-inflicted pain is a
part of a religious experience.


Religion





Religious beliefs shape how the world is viewed.
Is illness a punishment? The devil’s work? An
evil spell? Bad karma?
For Hispanics, the curandero is a trusted healer.
For Lakota Sioux, the ritual Vision Quest,
praying and fasting at a holy site is life
changing.

Remember there are as many
differences
Between individuals in the same
culture as there are between
individuals in different cultures!

Two African American
families, one lesbian
and the other, multi-racial.

German Consumers
Suggestions from our Gillespie County MH staff

What generation German?
 Would they feel more comfortable
speaking in German?


A consumer reacting to internal stimuli.

German Consumers
Suggestions from our Gillespie MHC staff in Fredericksburg

They may be resistant to seeking
mental services.
They may be reluctant to take medication.
They may “keep things within the family.”
They are concerned about the stigma.

German Consumers
They may feel it’s a character flaw or a
disgrace.
 They are very concerned about
confidentiality.
 Drinking alcohol is an accepted part of
their culture.
 Teen drinking may be acceptable in their
family.


Hispanic Consumers
from the U.S. Census, 1/23/03 Houston Chronicle

Hispanics are the largest minority group in
the U.S. with 37 million people.
 Texas is approximately 32 percent
Hispanic
 11.5 % African American,
 3.3% Other
 53.1% Anglo


Treatment Issues for Hispanic
Consumers
Do we need an interpreter?
 Is the person Tejano or from Mexico?
What generation Hispanic?
Is the person using a curandero?

Treatment issues for Hispanic
Consumers
Hallucinations are natural in their
religion.
 Hearing the voice of a loved one or having
hallucinations might be an expectations
when celebrating the Day of the Dead.
 Hispanic families are patriarchal.


Hispanic Consumers and
The Day of the Dead
A man is dressed in a skeleton
costume to portray death
in a celebration of
Dia de los Muertos,
The Day of the Dead.
People visit the graves of their
dead relatives to honor them.

Native Americans

Treatment Issues for Native
American Consumers
 Impact of racism,unemployment,and poverty.
 Coping with reservation life and
assimilation in mainstream culture.
 Consider the obesity, diabetes,
hypertension, and alcoholism in adults
and fetal alcohol syndrome in children.
 High use of native healers in the Southwest.

African Americans

African Americans
from the Houston Chronicle, 1/23/03

There are 36.2 million Americans who
identify themselves as “black only.”
 37.7 million identify themselves as “black
and at least one other race.”
 11.5% of Texans are African Americans.


Treatment Issues for African
American
Assess for co-occurring substance use
disorders and alcoholism.
 Address complications of obesity,
hypertension, diabetes,congestive heart
failure, asthma, and cancer.
 Sickle cell anemia is another illness
specific to African Americans.


Treatment Issues for African
Americans
Matriarchy; Mom or grandmother are the
dominant family figures.
 Lack of male role models and intact
families.
 Extended family or the Church may be
supports.


Treatment Issues for African
Americans


There is discrimination within their own
group based on skin color, hair texture,
class, values, etc.

Treatment Issues for Asians

Asians rarely seek help until its very severe.
Asians have extremely low admissions to state hospitals.
Mental illness is considered shameful. It’s hidden.
Is an interpreter needed?

Treatment Issues for Asians
Focus on physical symptoms.
 Asians are sensitive to medication.
 Give ½ the standard dose.
 Asians may use traditional healers and
herbal medicine.
 Asians may “flush” when drinking
alcohol.


Asian Consumers

Acupuncture has been used to treat
pain, schizophrenia, depression, and addictions.

Treatment Issues for Asians
Asian Cultures are patriarchal.
 The males in the family have the authority.
 Asians are more formal and inhibited in
their social behavior.


Older Adults

Treatment Issues for Older
Adults
Are they aware they need help?

Treatment Issues for Older
Adults
Is their mental illness caused by medicine?
 Do their medical problems cause or
complicate their mental illness?
 Is there Elder Abuse?


Gay Men and Lesbian Women
May struggle with homophobia and“being in the
closet” at work and with their families.
Gay people may want marriage, children, partner
benefits, etc., but may endure legal barriers.

Gay and Lesbian Women
Gay people often have specific health
issues related to their sexual practices.
 HIV, AIDS and STD’s are still concerns
with Gay men.
 People may be grieving the death of a
partner or friends who’ve died from AIDS,
or coping with living with AIDS or being
HIV+ themselves.


Treatment Issues for Gay and
Lesbians
Explore childhood abuse issues and
Domestic Violence..
 Assess for substance use and alcoholism.
 Sex enhancing drug use may be common
among some gay men.


Physically Challenged
Can they get to treatment?
Deal with their frustration and depression
Re: their disability.
 Do they need vocational assistance?

Mentally Challenged

Treatment Issues of Mentally
Challenged
They need to have meaningful activity
and purpose in their lives.
 They need to feel acknowledged and
appreciated.
 They need safety, structure, and security.
 Lack of continuity can cause crisis!
 They may need vocational assistance.


Winona Ryder

December 12, 2001,
Winona Ryder shoplifted
$5,560.40 designer items
from Saks Fifth Avenue in
Beverley Hills.

Twice an Academy
Award Nominated
actress

She had the following 8 drugs in
her possession:
Liquid demerol
 Liquid Diazepam
 Vicodin
 Percodan
 Valium
 Morphine sulfate
 Endocet (containing Oxycodone)


Patterns of Drug Use are highly
Regional.
 Drugs,

routes of administration, street
names, patterns of use, and drug
combinations may differ greatly, not
only between individuals from
different cultures, but different parts
of the country or even different parts
of the city.

Drugs of Choice
Native Americans-alcohol
 Asians-gambling, work
 Gay Men-stimulants, amyl nitrate, ecstasy
 “Rich”-prescription drugs, Internet porn
 M.D.’s –Vicodin


Drugs of Choice
Young adults-marijuana, cigarettes
 Geriatrics-alcohol, pills
 Sex Workers-crack cocaine, IV speedballs
 Screen mentally retarded for abuse too!


How Do We Best Serve Our
Consumers?




Examine own stereotypes.
Build trust.
Use People First language!

How do we best serve our
consumers?
Pronounce the person’s name correctly.
 Get an interpreter, if necessary.
 Educate yourself from the consumer, his
family, co-workers, etc.
 Remember differences do matter!



Slide 35

Cultural Competence
Integrating Differences
into Community Services

Objectives
Understand Stigma.
 Understand Culture Competency.
 Learn Culturally competent care for
people with Mental Health, Mental
Retardation and Addictions.


We live in an world
which often separates us.
Racism
 Sexism
 Ageism
 Feminism
 Classism
 Atheism


“Different” people are
“Stigmatized”

Mentally retarded inmates in a sanitorium in Germany

Stigma
Definitions from the U. of Chicago PSR Training Manual

“Stigmas are negative attitudes about a
group that lead to depriving them of
some fair opportunities.”

Stigma is related to…..
Stereotypes
Prejudice
Discrimination

Stereotypes
from The Asian Health Coalition of Illinois

Stereotypes are exaggerated beliefs
or fixed ideas about a person or
group which is held by people and
sustained by selective perception and
selective forgetting.

Prejudice
from The Asian Health Coalition of Illinois

Prejudice is a preconceived idea or
negative attitude formed before the
facts are known and sustained over
generalizations. A bias without
reason, resisting all evidence…

Discrimination
from The Asian Health Coalition of Illinois

Discrimination refers to treatment in
favor or against a person based on
the group to which that person
belongs and not on merit.

Stigmatized People…..
Experience being stereotyped and
are often the object of
discrimination and prejudice.

People are often stigmatized by:













Mental Illness
Mental Retardation
Physical Disability (including blindness, deafness)
Alcoholism /and or Drug Addiction
HIV or AIDS, Cancer or other terminal illnesses
Criminal behavior
Poverty
Alternative Lifestyles/sexual orientation
Wheelchair bound
Gender
Obesity

All our Consumers belong to
stigmatized groups!

Stigmatized People
Consumers and their families
can’t navigate the bureaucracy
even if resources are there.
It’s too frustrating!

Use People First Language
“I am more than my
illness….Don’t call me
“the schizophrenic,
“the addict” or
“the retard.”

As human beings, we have many
similarities…..
But, who we really are, is often
derived from our original family of origin
and our current lifestyle.

The Bottom Line:
People are different, even within
their own culture!
These differences matter when
planning and providing services.

National Mental Health
Association
“For Mental Health consumers, both
access to the services and the effectiveness
of the care they receive are greatly affected
by the degree to which the delivery system
is“culturally competent.”

Some important definitions
Related to Cultural Competency

Culture

from King,et. al

The Office of Special Programs, U.S. Dept. of Education

“The integrated patterns of human
behavior that includes thoughts,
communications, actions, customs,
beliefs,values, and institutions of
racial, ethnic, religious, or social
groups.”

Cultural Sensitivity
An awareness and respect of a
person’s cultural beliefs and
values.
Culhane-Pera, et .al

Cultural Competency
 Skills

(that translate into)
 Behaviors, Practices, Attitudes, and
 Policies
That enable an individual, agency, or
system to effectively serve culturally
diverse communities.
from The Asian Health Coalition of Illinois

Here at Hill Country MHDDC
Consumers are very diverse in their
language and culture.

61% of our Consumers are
Caucasian Americans
Many have German
backgrounds.

Our Consumers are …..

n
1% NativeAmerican

33% Hispanic
1% Asian

3% African
American

1% are “Others”

Consumers Have Many
Different Lifestyles

Lifestyles

They have many different
beliefs.

Can We Communicate?
Think Language first!
 Do we need an interpreter?
 Communicate respectfully.
 Be sensitive to the consumer and the family.
 Consider your dress, tone of voice, eye contact,
location, seating arrangement, privacy, etc.


Is our approach culturally
appropriate?
“What do you call your problem?”
“What name does it have?”
“What do you think caused your problem?”
“Why do you think it started when it did?”
From Arthur Kleinman’s question protocol in“Culture,Illness, and Care:
Clinical Lessons from Anthropologic and Cross Cultural Research”,
Ann.Intern.Med. 1978:Vol.88, pg.251-258

Important Issues to Consider…





Impact of religion.
How are women, men, elders, and children
treated in their culture?
Is there domestic violence?
Ethnic minorities generally underutilize
outpatient services, although African-Americans
are over-represented in inpatient setting.

Diagnosis






Minorities with Bipolar Disorder are often
diagnosed with schizophrenia. (Mukherjee,et al)
African Americans are over diagnosed with
schizophrenia and under diagnosed with mood
disorders. (Bell )
A mental health consumer’s addictions may not
be treated.
The elderly may not be assessed for substance
abuse or alcoholism.

Diagnosis
A person with a primary addiction problem
might not be treated for a co-occurring mental
illness.
 Learning disabilities may not be identified in
individuals with mental illness or substance
abuse.
 A person with mental retardation may not be
treated for mental illness or substance abuse.


Diagnosis
Post Traumatic Stress Disorder is often
undiagnosed in people suffering from
Domestic Abuse or other trauma.
 Children who are witnessing or are
victims of domestic abuse or another
trauma, may be misdiagnosed with
Attention Deficit Hyperactivity Disorder.


Medication Differences





Asians and Hispanics need lower doses of antipsychotics.
African Americans use the same doses of antipsychotics, but lower doses of lithium.
The elderly need lower dosages of medications.
Thus, metabolism of drugs varies with age and
ethnicity and is critical in prescribing
medications.

From “Making Room for Culture in Psychiatry” by Lin, et al.

Pain Tolerance
Men and women tolerate pain differently.
 Cultures tolerate pain differently.
 People with addictions develop a
hypersensitivity to pain.
 In certain cultures, self-inflicted pain is a
part of a religious experience.


Religion





Religious beliefs shape how the world is viewed.
Is illness a punishment? The devil’s work? An
evil spell? Bad karma?
For Hispanics, the curandero is a trusted healer.
For Lakota Sioux, the ritual Vision Quest,
praying and fasting at a holy site is life
changing.

Remember there are as many
differences
Between individuals in the same
culture as there are between
individuals in different cultures!

Two African American
families, one lesbian
and the other, multi-racial.

German Consumers
Suggestions from our Gillespie County MH staff

What generation German?
 Would they feel more comfortable
speaking in German?


A consumer reacting to internal stimuli.

German Consumers
Suggestions from our Gillespie MHC staff in Fredericksburg

They may be resistant to seeking
mental services.
They may be reluctant to take medication.
They may “keep things within the family.”
They are concerned about the stigma.

German Consumers
They may feel it’s a character flaw or a
disgrace.
 They are very concerned about
confidentiality.
 Drinking alcohol is an accepted part of
their culture.
 Teen drinking may be acceptable in their
family.


Hispanic Consumers
from the U.S. Census, 1/23/03 Houston Chronicle

Hispanics are the largest minority group in
the U.S. with 37 million people.
 Texas is approximately 32 percent
Hispanic
 11.5 % African American,
 3.3% Other
 53.1% Anglo


Treatment Issues for Hispanic
Consumers
Do we need an interpreter?
 Is the person Tejano or from Mexico?
What generation Hispanic?
Is the person using a curandero?

Treatment issues for Hispanic
Consumers
Hallucinations are natural in their
religion.
 Hearing the voice of a loved one or having
hallucinations might be an expectations
when celebrating the Day of the Dead.
 Hispanic families are patriarchal.


Hispanic Consumers and
The Day of the Dead
A man is dressed in a skeleton
costume to portray death
in a celebration of
Dia de los Muertos,
The Day of the Dead.
People visit the graves of their
dead relatives to honor them.

Native Americans

Treatment Issues for Native
American Consumers
 Impact of racism,unemployment,and poverty.
 Coping with reservation life and
assimilation in mainstream culture.
 Consider the obesity, diabetes,
hypertension, and alcoholism in adults
and fetal alcohol syndrome in children.
 High use of native healers in the Southwest.

African Americans

African Americans
from the Houston Chronicle, 1/23/03

There are 36.2 million Americans who
identify themselves as “black only.”
 37.7 million identify themselves as “black
and at least one other race.”
 11.5% of Texans are African Americans.


Treatment Issues for African
American
Assess for co-occurring substance use
disorders and alcoholism.
 Address complications of obesity,
hypertension, diabetes,congestive heart
failure, asthma, and cancer.
 Sickle cell anemia is another illness
specific to African Americans.


Treatment Issues for African
Americans
Matriarchy; Mom or grandmother are the
dominant family figures.
 Lack of male role models and intact
families.
 Extended family or the Church may be
supports.


Treatment Issues for African
Americans


There is discrimination within their own
group based on skin color, hair texture,
class, values, etc.

Treatment Issues for Asians

Asians rarely seek help until its very severe.
Asians have extremely low admissions to state hospitals.
Mental illness is considered shameful. It’s hidden.
Is an interpreter needed?

Treatment Issues for Asians
Focus on physical symptoms.
 Asians are sensitive to medication.
 Give ½ the standard dose.
 Asians may use traditional healers and
herbal medicine.
 Asians may “flush” when drinking
alcohol.


Asian Consumers

Acupuncture has been used to treat
pain, schizophrenia, depression, and addictions.

Treatment Issues for Asians
Asian Cultures are patriarchal.
 The males in the family have the authority.
 Asians are more formal and inhibited in
their social behavior.


Older Adults

Treatment Issues for Older
Adults
Are they aware they need help?

Treatment Issues for Older
Adults
Is their mental illness caused by medicine?
 Do their medical problems cause or
complicate their mental illness?
 Is there Elder Abuse?


Gay Men and Lesbian Women
May struggle with homophobia and“being in the
closet” at work and with their families.
Gay people may want marriage, children, partner
benefits, etc., but may endure legal barriers.

Gay and Lesbian Women
Gay people often have specific health
issues related to their sexual practices.
 HIV, AIDS and STD’s are still concerns
with Gay men.
 People may be grieving the death of a
partner or friends who’ve died from AIDS,
or coping with living with AIDS or being
HIV+ themselves.


Treatment Issues for Gay and
Lesbians
Explore childhood abuse issues and
Domestic Violence..
 Assess for substance use and alcoholism.
 Sex enhancing drug use may be common
among some gay men.


Physically Challenged
Can they get to treatment?
Deal with their frustration and depression
Re: their disability.
 Do they need vocational assistance?

Mentally Challenged

Treatment Issues of Mentally
Challenged
They need to have meaningful activity
and purpose in their lives.
 They need to feel acknowledged and
appreciated.
 They need safety, structure, and security.
 Lack of continuity can cause crisis!
 They may need vocational assistance.


Winona Ryder

December 12, 2001,
Winona Ryder shoplifted
$5,560.40 designer items
from Saks Fifth Avenue in
Beverley Hills.

Twice an Academy
Award Nominated
actress

She had the following 8 drugs in
her possession:
Liquid demerol
 Liquid Diazepam
 Vicodin
 Percodan
 Valium
 Morphine sulfate
 Endocet (containing Oxycodone)


Patterns of Drug Use are highly
Regional.
 Drugs,

routes of administration, street
names, patterns of use, and drug
combinations may differ greatly, not
only between individuals from
different cultures, but different parts
of the country or even different parts
of the city.

Drugs of Choice
Native Americans-alcohol
 Asians-gambling, work
 Gay Men-stimulants, amyl nitrate, ecstasy
 “Rich”-prescription drugs, Internet porn
 M.D.’s –Vicodin


Drugs of Choice
Young adults-marijuana, cigarettes
 Geriatrics-alcohol, pills
 Sex Workers-crack cocaine, IV speedballs
 Screen mentally retarded for abuse too!


How Do We Best Serve Our
Consumers?




Examine own stereotypes.
Build trust.
Use People First language!

How do we best serve our
consumers?
Pronounce the person’s name correctly.
 Get an interpreter, if necessary.
 Educate yourself from the consumer, his
family, co-workers, etc.
 Remember differences do matter!



Slide 36

Cultural Competence
Integrating Differences
into Community Services

Objectives
Understand Stigma.
 Understand Culture Competency.
 Learn Culturally competent care for
people with Mental Health, Mental
Retardation and Addictions.


We live in an world
which often separates us.
Racism
 Sexism
 Ageism
 Feminism
 Classism
 Atheism


“Different” people are
“Stigmatized”

Mentally retarded inmates in a sanitorium in Germany

Stigma
Definitions from the U. of Chicago PSR Training Manual

“Stigmas are negative attitudes about a
group that lead to depriving them of
some fair opportunities.”

Stigma is related to…..
Stereotypes
Prejudice
Discrimination

Stereotypes
from The Asian Health Coalition of Illinois

Stereotypes are exaggerated beliefs
or fixed ideas about a person or
group which is held by people and
sustained by selective perception and
selective forgetting.

Prejudice
from The Asian Health Coalition of Illinois

Prejudice is a preconceived idea or
negative attitude formed before the
facts are known and sustained over
generalizations. A bias without
reason, resisting all evidence…

Discrimination
from The Asian Health Coalition of Illinois

Discrimination refers to treatment in
favor or against a person based on
the group to which that person
belongs and not on merit.

Stigmatized People…..
Experience being stereotyped and
are often the object of
discrimination and prejudice.

People are often stigmatized by:













Mental Illness
Mental Retardation
Physical Disability (including blindness, deafness)
Alcoholism /and or Drug Addiction
HIV or AIDS, Cancer or other terminal illnesses
Criminal behavior
Poverty
Alternative Lifestyles/sexual orientation
Wheelchair bound
Gender
Obesity

All our Consumers belong to
stigmatized groups!

Stigmatized People
Consumers and their families
can’t navigate the bureaucracy
even if resources are there.
It’s too frustrating!

Use People First Language
“I am more than my
illness….Don’t call me
“the schizophrenic,
“the addict” or
“the retard.”

As human beings, we have many
similarities…..
But, who we really are, is often
derived from our original family of origin
and our current lifestyle.

The Bottom Line:
People are different, even within
their own culture!
These differences matter when
planning and providing services.

National Mental Health
Association
“For Mental Health consumers, both
access to the services and the effectiveness
of the care they receive are greatly affected
by the degree to which the delivery system
is“culturally competent.”

Some important definitions
Related to Cultural Competency

Culture

from King,et. al

The Office of Special Programs, U.S. Dept. of Education

“The integrated patterns of human
behavior that includes thoughts,
communications, actions, customs,
beliefs,values, and institutions of
racial, ethnic, religious, or social
groups.”

Cultural Sensitivity
An awareness and respect of a
person’s cultural beliefs and
values.
Culhane-Pera, et .al

Cultural Competency
 Skills

(that translate into)
 Behaviors, Practices, Attitudes, and
 Policies
That enable an individual, agency, or
system to effectively serve culturally
diverse communities.
from The Asian Health Coalition of Illinois

Here at Hill Country MHDDC
Consumers are very diverse in their
language and culture.

61% of our Consumers are
Caucasian Americans
Many have German
backgrounds.

Our Consumers are …..

n
1% NativeAmerican

33% Hispanic
1% Asian

3% African
American

1% are “Others”

Consumers Have Many
Different Lifestyles

Lifestyles

They have many different
beliefs.

Can We Communicate?
Think Language first!
 Do we need an interpreter?
 Communicate respectfully.
 Be sensitive to the consumer and the family.
 Consider your dress, tone of voice, eye contact,
location, seating arrangement, privacy, etc.


Is our approach culturally
appropriate?
“What do you call your problem?”
“What name does it have?”
“What do you think caused your problem?”
“Why do you think it started when it did?”
From Arthur Kleinman’s question protocol in“Culture,Illness, and Care:
Clinical Lessons from Anthropologic and Cross Cultural Research”,
Ann.Intern.Med. 1978:Vol.88, pg.251-258

Important Issues to Consider…





Impact of religion.
How are women, men, elders, and children
treated in their culture?
Is there domestic violence?
Ethnic minorities generally underutilize
outpatient services, although African-Americans
are over-represented in inpatient setting.

Diagnosis






Minorities with Bipolar Disorder are often
diagnosed with schizophrenia. (Mukherjee,et al)
African Americans are over diagnosed with
schizophrenia and under diagnosed with mood
disorders. (Bell )
A mental health consumer’s addictions may not
be treated.
The elderly may not be assessed for substance
abuse or alcoholism.

Diagnosis
A person with a primary addiction problem
might not be treated for a co-occurring mental
illness.
 Learning disabilities may not be identified in
individuals with mental illness or substance
abuse.
 A person with mental retardation may not be
treated for mental illness or substance abuse.


Diagnosis
Post Traumatic Stress Disorder is often
undiagnosed in people suffering from
Domestic Abuse or other trauma.
 Children who are witnessing or are
victims of domestic abuse or another
trauma, may be misdiagnosed with
Attention Deficit Hyperactivity Disorder.


Medication Differences





Asians and Hispanics need lower doses of antipsychotics.
African Americans use the same doses of antipsychotics, but lower doses of lithium.
The elderly need lower dosages of medications.
Thus, metabolism of drugs varies with age and
ethnicity and is critical in prescribing
medications.

From “Making Room for Culture in Psychiatry” by Lin, et al.

Pain Tolerance
Men and women tolerate pain differently.
 Cultures tolerate pain differently.
 People with addictions develop a
hypersensitivity to pain.
 In certain cultures, self-inflicted pain is a
part of a religious experience.


Religion





Religious beliefs shape how the world is viewed.
Is illness a punishment? The devil’s work? An
evil spell? Bad karma?
For Hispanics, the curandero is a trusted healer.
For Lakota Sioux, the ritual Vision Quest,
praying and fasting at a holy site is life
changing.

Remember there are as many
differences
Between individuals in the same
culture as there are between
individuals in different cultures!

Two African American
families, one lesbian
and the other, multi-racial.

German Consumers
Suggestions from our Gillespie County MH staff

What generation German?
 Would they feel more comfortable
speaking in German?


A consumer reacting to internal stimuli.

German Consumers
Suggestions from our Gillespie MHC staff in Fredericksburg

They may be resistant to seeking
mental services.
They may be reluctant to take medication.
They may “keep things within the family.”
They are concerned about the stigma.

German Consumers
They may feel it’s a character flaw or a
disgrace.
 They are very concerned about
confidentiality.
 Drinking alcohol is an accepted part of
their culture.
 Teen drinking may be acceptable in their
family.


Hispanic Consumers
from the U.S. Census, 1/23/03 Houston Chronicle

Hispanics are the largest minority group in
the U.S. with 37 million people.
 Texas is approximately 32 percent
Hispanic
 11.5 % African American,
 3.3% Other
 53.1% Anglo


Treatment Issues for Hispanic
Consumers
Do we need an interpreter?
 Is the person Tejano or from Mexico?
What generation Hispanic?
Is the person using a curandero?

Treatment issues for Hispanic
Consumers
Hallucinations are natural in their
religion.
 Hearing the voice of a loved one or having
hallucinations might be an expectations
when celebrating the Day of the Dead.
 Hispanic families are patriarchal.


Hispanic Consumers and
The Day of the Dead
A man is dressed in a skeleton
costume to portray death
in a celebration of
Dia de los Muertos,
The Day of the Dead.
People visit the graves of their
dead relatives to honor them.

Native Americans

Treatment Issues for Native
American Consumers
 Impact of racism,unemployment,and poverty.
 Coping with reservation life and
assimilation in mainstream culture.
 Consider the obesity, diabetes,
hypertension, and alcoholism in adults
and fetal alcohol syndrome in children.
 High use of native healers in the Southwest.

African Americans

African Americans
from the Houston Chronicle, 1/23/03

There are 36.2 million Americans who
identify themselves as “black only.”
 37.7 million identify themselves as “black
and at least one other race.”
 11.5% of Texans are African Americans.


Treatment Issues for African
American
Assess for co-occurring substance use
disorders and alcoholism.
 Address complications of obesity,
hypertension, diabetes,congestive heart
failure, asthma, and cancer.
 Sickle cell anemia is another illness
specific to African Americans.


Treatment Issues for African
Americans
Matriarchy; Mom or grandmother are the
dominant family figures.
 Lack of male role models and intact
families.
 Extended family or the Church may be
supports.


Treatment Issues for African
Americans


There is discrimination within their own
group based on skin color, hair texture,
class, values, etc.

Treatment Issues for Asians

Asians rarely seek help until its very severe.
Asians have extremely low admissions to state hospitals.
Mental illness is considered shameful. It’s hidden.
Is an interpreter needed?

Treatment Issues for Asians
Focus on physical symptoms.
 Asians are sensitive to medication.
 Give ½ the standard dose.
 Asians may use traditional healers and
herbal medicine.
 Asians may “flush” when drinking
alcohol.


Asian Consumers

Acupuncture has been used to treat
pain, schizophrenia, depression, and addictions.

Treatment Issues for Asians
Asian Cultures are patriarchal.
 The males in the family have the authority.
 Asians are more formal and inhibited in
their social behavior.


Older Adults

Treatment Issues for Older
Adults
Are they aware they need help?

Treatment Issues for Older
Adults
Is their mental illness caused by medicine?
 Do their medical problems cause or
complicate their mental illness?
 Is there Elder Abuse?


Gay Men and Lesbian Women
May struggle with homophobia and“being in the
closet” at work and with their families.
Gay people may want marriage, children, partner
benefits, etc., but may endure legal barriers.

Gay and Lesbian Women
Gay people often have specific health
issues related to their sexual practices.
 HIV, AIDS and STD’s are still concerns
with Gay men.
 People may be grieving the death of a
partner or friends who’ve died from AIDS,
or coping with living with AIDS or being
HIV+ themselves.


Treatment Issues for Gay and
Lesbians
Explore childhood abuse issues and
Domestic Violence..
 Assess for substance use and alcoholism.
 Sex enhancing drug use may be common
among some gay men.


Physically Challenged
Can they get to treatment?
Deal with their frustration and depression
Re: their disability.
 Do they need vocational assistance?

Mentally Challenged

Treatment Issues of Mentally
Challenged
They need to have meaningful activity
and purpose in their lives.
 They need to feel acknowledged and
appreciated.
 They need safety, structure, and security.
 Lack of continuity can cause crisis!
 They may need vocational assistance.


Winona Ryder

December 12, 2001,
Winona Ryder shoplifted
$5,560.40 designer items
from Saks Fifth Avenue in
Beverley Hills.

Twice an Academy
Award Nominated
actress

She had the following 8 drugs in
her possession:
Liquid demerol
 Liquid Diazepam
 Vicodin
 Percodan
 Valium
 Morphine sulfate
 Endocet (containing Oxycodone)


Patterns of Drug Use are highly
Regional.
 Drugs,

routes of administration, street
names, patterns of use, and drug
combinations may differ greatly, not
only between individuals from
different cultures, but different parts
of the country or even different parts
of the city.

Drugs of Choice
Native Americans-alcohol
 Asians-gambling, work
 Gay Men-stimulants, amyl nitrate, ecstasy
 “Rich”-prescription drugs, Internet porn
 M.D.’s –Vicodin


Drugs of Choice
Young adults-marijuana, cigarettes
 Geriatrics-alcohol, pills
 Sex Workers-crack cocaine, IV speedballs
 Screen mentally retarded for abuse too!


How Do We Best Serve Our
Consumers?




Examine own stereotypes.
Build trust.
Use People First language!

How do we best serve our
consumers?
Pronounce the person’s name correctly.
 Get an interpreter, if necessary.
 Educate yourself from the consumer, his
family, co-workers, etc.
 Remember differences do matter!



Slide 37

Cultural Competence
Integrating Differences
into Community Services

Objectives
Understand Stigma.
 Understand Culture Competency.
 Learn Culturally competent care for
people with Mental Health, Mental
Retardation and Addictions.


We live in an world
which often separates us.
Racism
 Sexism
 Ageism
 Feminism
 Classism
 Atheism


“Different” people are
“Stigmatized”

Mentally retarded inmates in a sanitorium in Germany

Stigma
Definitions from the U. of Chicago PSR Training Manual

“Stigmas are negative attitudes about a
group that lead to depriving them of
some fair opportunities.”

Stigma is related to…..
Stereotypes
Prejudice
Discrimination

Stereotypes
from The Asian Health Coalition of Illinois

Stereotypes are exaggerated beliefs
or fixed ideas about a person or
group which is held by people and
sustained by selective perception and
selective forgetting.

Prejudice
from The Asian Health Coalition of Illinois

Prejudice is a preconceived idea or
negative attitude formed before the
facts are known and sustained over
generalizations. A bias without
reason, resisting all evidence…

Discrimination
from The Asian Health Coalition of Illinois

Discrimination refers to treatment in
favor or against a person based on
the group to which that person
belongs and not on merit.

Stigmatized People…..
Experience being stereotyped and
are often the object of
discrimination and prejudice.

People are often stigmatized by:













Mental Illness
Mental Retardation
Physical Disability (including blindness, deafness)
Alcoholism /and or Drug Addiction
HIV or AIDS, Cancer or other terminal illnesses
Criminal behavior
Poverty
Alternative Lifestyles/sexual orientation
Wheelchair bound
Gender
Obesity

All our Consumers belong to
stigmatized groups!

Stigmatized People
Consumers and their families
can’t navigate the bureaucracy
even if resources are there.
It’s too frustrating!

Use People First Language
“I am more than my
illness….Don’t call me
“the schizophrenic,
“the addict” or
“the retard.”

As human beings, we have many
similarities…..
But, who we really are, is often
derived from our original family of origin
and our current lifestyle.

The Bottom Line:
People are different, even within
their own culture!
These differences matter when
planning and providing services.

National Mental Health
Association
“For Mental Health consumers, both
access to the services and the effectiveness
of the care they receive are greatly affected
by the degree to which the delivery system
is“culturally competent.”

Some important definitions
Related to Cultural Competency

Culture

from King,et. al

The Office of Special Programs, U.S. Dept. of Education

“The integrated patterns of human
behavior that includes thoughts,
communications, actions, customs,
beliefs,values, and institutions of
racial, ethnic, religious, or social
groups.”

Cultural Sensitivity
An awareness and respect of a
person’s cultural beliefs and
values.
Culhane-Pera, et .al

Cultural Competency
 Skills

(that translate into)
 Behaviors, Practices, Attitudes, and
 Policies
That enable an individual, agency, or
system to effectively serve culturally
diverse communities.
from The Asian Health Coalition of Illinois

Here at Hill Country MHDDC
Consumers are very diverse in their
language and culture.

61% of our Consumers are
Caucasian Americans
Many have German
backgrounds.

Our Consumers are …..

n
1% NativeAmerican

33% Hispanic
1% Asian

3% African
American

1% are “Others”

Consumers Have Many
Different Lifestyles

Lifestyles

They have many different
beliefs.

Can We Communicate?
Think Language first!
 Do we need an interpreter?
 Communicate respectfully.
 Be sensitive to the consumer and the family.
 Consider your dress, tone of voice, eye contact,
location, seating arrangement, privacy, etc.


Is our approach culturally
appropriate?
“What do you call your problem?”
“What name does it have?”
“What do you think caused your problem?”
“Why do you think it started when it did?”
From Arthur Kleinman’s question protocol in“Culture,Illness, and Care:
Clinical Lessons from Anthropologic and Cross Cultural Research”,
Ann.Intern.Med. 1978:Vol.88, pg.251-258

Important Issues to Consider…





Impact of religion.
How are women, men, elders, and children
treated in their culture?
Is there domestic violence?
Ethnic minorities generally underutilize
outpatient services, although African-Americans
are over-represented in inpatient setting.

Diagnosis






Minorities with Bipolar Disorder are often
diagnosed with schizophrenia. (Mukherjee,et al)
African Americans are over diagnosed with
schizophrenia and under diagnosed with mood
disorders. (Bell )
A mental health consumer’s addictions may not
be treated.
The elderly may not be assessed for substance
abuse or alcoholism.

Diagnosis
A person with a primary addiction problem
might not be treated for a co-occurring mental
illness.
 Learning disabilities may not be identified in
individuals with mental illness or substance
abuse.
 A person with mental retardation may not be
treated for mental illness or substance abuse.


Diagnosis
Post Traumatic Stress Disorder is often
undiagnosed in people suffering from
Domestic Abuse or other trauma.
 Children who are witnessing or are
victims of domestic abuse or another
trauma, may be misdiagnosed with
Attention Deficit Hyperactivity Disorder.


Medication Differences





Asians and Hispanics need lower doses of antipsychotics.
African Americans use the same doses of antipsychotics, but lower doses of lithium.
The elderly need lower dosages of medications.
Thus, metabolism of drugs varies with age and
ethnicity and is critical in prescribing
medications.

From “Making Room for Culture in Psychiatry” by Lin, et al.

Pain Tolerance
Men and women tolerate pain differently.
 Cultures tolerate pain differently.
 People with addictions develop a
hypersensitivity to pain.
 In certain cultures, self-inflicted pain is a
part of a religious experience.


Religion





Religious beliefs shape how the world is viewed.
Is illness a punishment? The devil’s work? An
evil spell? Bad karma?
For Hispanics, the curandero is a trusted healer.
For Lakota Sioux, the ritual Vision Quest,
praying and fasting at a holy site is life
changing.

Remember there are as many
differences
Between individuals in the same
culture as there are between
individuals in different cultures!

Two African American
families, one lesbian
and the other, multi-racial.

German Consumers
Suggestions from our Gillespie County MH staff

What generation German?
 Would they feel more comfortable
speaking in German?


A consumer reacting to internal stimuli.

German Consumers
Suggestions from our Gillespie MHC staff in Fredericksburg

They may be resistant to seeking
mental services.
They may be reluctant to take medication.
They may “keep things within the family.”
They are concerned about the stigma.

German Consumers
They may feel it’s a character flaw or a
disgrace.
 They are very concerned about
confidentiality.
 Drinking alcohol is an accepted part of
their culture.
 Teen drinking may be acceptable in their
family.


Hispanic Consumers
from the U.S. Census, 1/23/03 Houston Chronicle

Hispanics are the largest minority group in
the U.S. with 37 million people.
 Texas is approximately 32 percent
Hispanic
 11.5 % African American,
 3.3% Other
 53.1% Anglo


Treatment Issues for Hispanic
Consumers
Do we need an interpreter?
 Is the person Tejano or from Mexico?
What generation Hispanic?
Is the person using a curandero?

Treatment issues for Hispanic
Consumers
Hallucinations are natural in their
religion.
 Hearing the voice of a loved one or having
hallucinations might be an expectations
when celebrating the Day of the Dead.
 Hispanic families are patriarchal.


Hispanic Consumers and
The Day of the Dead
A man is dressed in a skeleton
costume to portray death
in a celebration of
Dia de los Muertos,
The Day of the Dead.
People visit the graves of their
dead relatives to honor them.

Native Americans

Treatment Issues for Native
American Consumers
 Impact of racism,unemployment,and poverty.
 Coping with reservation life and
assimilation in mainstream culture.
 Consider the obesity, diabetes,
hypertension, and alcoholism in adults
and fetal alcohol syndrome in children.
 High use of native healers in the Southwest.

African Americans

African Americans
from the Houston Chronicle, 1/23/03

There are 36.2 million Americans who
identify themselves as “black only.”
 37.7 million identify themselves as “black
and at least one other race.”
 11.5% of Texans are African Americans.


Treatment Issues for African
American
Assess for co-occurring substance use
disorders and alcoholism.
 Address complications of obesity,
hypertension, diabetes,congestive heart
failure, asthma, and cancer.
 Sickle cell anemia is another illness
specific to African Americans.


Treatment Issues for African
Americans
Matriarchy; Mom or grandmother are the
dominant family figures.
 Lack of male role models and intact
families.
 Extended family or the Church may be
supports.


Treatment Issues for African
Americans


There is discrimination within their own
group based on skin color, hair texture,
class, values, etc.

Treatment Issues for Asians

Asians rarely seek help until its very severe.
Asians have extremely low admissions to state hospitals.
Mental illness is considered shameful. It’s hidden.
Is an interpreter needed?

Treatment Issues for Asians
Focus on physical symptoms.
 Asians are sensitive to medication.
 Give ½ the standard dose.
 Asians may use traditional healers and
herbal medicine.
 Asians may “flush” when drinking
alcohol.


Asian Consumers

Acupuncture has been used to treat
pain, schizophrenia, depression, and addictions.

Treatment Issues for Asians
Asian Cultures are patriarchal.
 The males in the family have the authority.
 Asians are more formal and inhibited in
their social behavior.


Older Adults

Treatment Issues for Older
Adults
Are they aware they need help?

Treatment Issues for Older
Adults
Is their mental illness caused by medicine?
 Do their medical problems cause or
complicate their mental illness?
 Is there Elder Abuse?


Gay Men and Lesbian Women
May struggle with homophobia and“being in the
closet” at work and with their families.
Gay people may want marriage, children, partner
benefits, etc., but may endure legal barriers.

Gay and Lesbian Women
Gay people often have specific health
issues related to their sexual practices.
 HIV, AIDS and STD’s are still concerns
with Gay men.
 People may be grieving the death of a
partner or friends who’ve died from AIDS,
or coping with living with AIDS or being
HIV+ themselves.


Treatment Issues for Gay and
Lesbians
Explore childhood abuse issues and
Domestic Violence..
 Assess for substance use and alcoholism.
 Sex enhancing drug use may be common
among some gay men.


Physically Challenged
Can they get to treatment?
Deal with their frustration and depression
Re: their disability.
 Do they need vocational assistance?

Mentally Challenged

Treatment Issues of Mentally
Challenged
They need to have meaningful activity
and purpose in their lives.
 They need to feel acknowledged and
appreciated.
 They need safety, structure, and security.
 Lack of continuity can cause crisis!
 They may need vocational assistance.


Winona Ryder

December 12, 2001,
Winona Ryder shoplifted
$5,560.40 designer items
from Saks Fifth Avenue in
Beverley Hills.

Twice an Academy
Award Nominated
actress

She had the following 8 drugs in
her possession:
Liquid demerol
 Liquid Diazepam
 Vicodin
 Percodan
 Valium
 Morphine sulfate
 Endocet (containing Oxycodone)


Patterns of Drug Use are highly
Regional.
 Drugs,

routes of administration, street
names, patterns of use, and drug
combinations may differ greatly, not
only between individuals from
different cultures, but different parts
of the country or even different parts
of the city.

Drugs of Choice
Native Americans-alcohol
 Asians-gambling, work
 Gay Men-stimulants, amyl nitrate, ecstasy
 “Rich”-prescription drugs, Internet porn
 M.D.’s –Vicodin


Drugs of Choice
Young adults-marijuana, cigarettes
 Geriatrics-alcohol, pills
 Sex Workers-crack cocaine, IV speedballs
 Screen mentally retarded for abuse too!


How Do We Best Serve Our
Consumers?




Examine own stereotypes.
Build trust.
Use People First language!

How do we best serve our
consumers?
Pronounce the person’s name correctly.
 Get an interpreter, if necessary.
 Educate yourself from the consumer, his
family, co-workers, etc.
 Remember differences do matter!



Slide 38

Cultural Competence
Integrating Differences
into Community Services

Objectives
Understand Stigma.
 Understand Culture Competency.
 Learn Culturally competent care for
people with Mental Health, Mental
Retardation and Addictions.


We live in an world
which often separates us.
Racism
 Sexism
 Ageism
 Feminism
 Classism
 Atheism


“Different” people are
“Stigmatized”

Mentally retarded inmates in a sanitorium in Germany

Stigma
Definitions from the U. of Chicago PSR Training Manual

“Stigmas are negative attitudes about a
group that lead to depriving them of
some fair opportunities.”

Stigma is related to…..
Stereotypes
Prejudice
Discrimination

Stereotypes
from The Asian Health Coalition of Illinois

Stereotypes are exaggerated beliefs
or fixed ideas about a person or
group which is held by people and
sustained by selective perception and
selective forgetting.

Prejudice
from The Asian Health Coalition of Illinois

Prejudice is a preconceived idea or
negative attitude formed before the
facts are known and sustained over
generalizations. A bias without
reason, resisting all evidence…

Discrimination
from The Asian Health Coalition of Illinois

Discrimination refers to treatment in
favor or against a person based on
the group to which that person
belongs and not on merit.

Stigmatized People…..
Experience being stereotyped and
are often the object of
discrimination and prejudice.

People are often stigmatized by:













Mental Illness
Mental Retardation
Physical Disability (including blindness, deafness)
Alcoholism /and or Drug Addiction
HIV or AIDS, Cancer or other terminal illnesses
Criminal behavior
Poverty
Alternative Lifestyles/sexual orientation
Wheelchair bound
Gender
Obesity

All our Consumers belong to
stigmatized groups!

Stigmatized People
Consumers and their families
can’t navigate the bureaucracy
even if resources are there.
It’s too frustrating!

Use People First Language
“I am more than my
illness….Don’t call me
“the schizophrenic,
“the addict” or
“the retard.”

As human beings, we have many
similarities…..
But, who we really are, is often
derived from our original family of origin
and our current lifestyle.

The Bottom Line:
People are different, even within
their own culture!
These differences matter when
planning and providing services.

National Mental Health
Association
“For Mental Health consumers, both
access to the services and the effectiveness
of the care they receive are greatly affected
by the degree to which the delivery system
is“culturally competent.”

Some important definitions
Related to Cultural Competency

Culture

from King,et. al

The Office of Special Programs, U.S. Dept. of Education

“The integrated patterns of human
behavior that includes thoughts,
communications, actions, customs,
beliefs,values, and institutions of
racial, ethnic, religious, or social
groups.”

Cultural Sensitivity
An awareness and respect of a
person’s cultural beliefs and
values.
Culhane-Pera, et .al

Cultural Competency
 Skills

(that translate into)
 Behaviors, Practices, Attitudes, and
 Policies
That enable an individual, agency, or
system to effectively serve culturally
diverse communities.
from The Asian Health Coalition of Illinois

Here at Hill Country MHDDC
Consumers are very diverse in their
language and culture.

61% of our Consumers are
Caucasian Americans
Many have German
backgrounds.

Our Consumers are …..

n
1% NativeAmerican

33% Hispanic
1% Asian

3% African
American

1% are “Others”

Consumers Have Many
Different Lifestyles

Lifestyles

They have many different
beliefs.

Can We Communicate?
Think Language first!
 Do we need an interpreter?
 Communicate respectfully.
 Be sensitive to the consumer and the family.
 Consider your dress, tone of voice, eye contact,
location, seating arrangement, privacy, etc.


Is our approach culturally
appropriate?
“What do you call your problem?”
“What name does it have?”
“What do you think caused your problem?”
“Why do you think it started when it did?”
From Arthur Kleinman’s question protocol in“Culture,Illness, and Care:
Clinical Lessons from Anthropologic and Cross Cultural Research”,
Ann.Intern.Med. 1978:Vol.88, pg.251-258

Important Issues to Consider…





Impact of religion.
How are women, men, elders, and children
treated in their culture?
Is there domestic violence?
Ethnic minorities generally underutilize
outpatient services, although African-Americans
are over-represented in inpatient setting.

Diagnosis






Minorities with Bipolar Disorder are often
diagnosed with schizophrenia. (Mukherjee,et al)
African Americans are over diagnosed with
schizophrenia and under diagnosed with mood
disorders. (Bell )
A mental health consumer’s addictions may not
be treated.
The elderly may not be assessed for substance
abuse or alcoholism.

Diagnosis
A person with a primary addiction problem
might not be treated for a co-occurring mental
illness.
 Learning disabilities may not be identified in
individuals with mental illness or substance
abuse.
 A person with mental retardation may not be
treated for mental illness or substance abuse.


Diagnosis
Post Traumatic Stress Disorder is often
undiagnosed in people suffering from
Domestic Abuse or other trauma.
 Children who are witnessing or are
victims of domestic abuse or another
trauma, may be misdiagnosed with
Attention Deficit Hyperactivity Disorder.


Medication Differences





Asians and Hispanics need lower doses of antipsychotics.
African Americans use the same doses of antipsychotics, but lower doses of lithium.
The elderly need lower dosages of medications.
Thus, metabolism of drugs varies with age and
ethnicity and is critical in prescribing
medications.

From “Making Room for Culture in Psychiatry” by Lin, et al.

Pain Tolerance
Men and women tolerate pain differently.
 Cultures tolerate pain differently.
 People with addictions develop a
hypersensitivity to pain.
 In certain cultures, self-inflicted pain is a
part of a religious experience.


Religion





Religious beliefs shape how the world is viewed.
Is illness a punishment? The devil’s work? An
evil spell? Bad karma?
For Hispanics, the curandero is a trusted healer.
For Lakota Sioux, the ritual Vision Quest,
praying and fasting at a holy site is life
changing.

Remember there are as many
differences
Between individuals in the same
culture as there are between
individuals in different cultures!

Two African American
families, one lesbian
and the other, multi-racial.

German Consumers
Suggestions from our Gillespie County MH staff

What generation German?
 Would they feel more comfortable
speaking in German?


A consumer reacting to internal stimuli.

German Consumers
Suggestions from our Gillespie MHC staff in Fredericksburg

They may be resistant to seeking
mental services.
They may be reluctant to take medication.
They may “keep things within the family.”
They are concerned about the stigma.

German Consumers
They may feel it’s a character flaw or a
disgrace.
 They are very concerned about
confidentiality.
 Drinking alcohol is an accepted part of
their culture.
 Teen drinking may be acceptable in their
family.


Hispanic Consumers
from the U.S. Census, 1/23/03 Houston Chronicle

Hispanics are the largest minority group in
the U.S. with 37 million people.
 Texas is approximately 32 percent
Hispanic
 11.5 % African American,
 3.3% Other
 53.1% Anglo


Treatment Issues for Hispanic
Consumers
Do we need an interpreter?
 Is the person Tejano or from Mexico?
What generation Hispanic?
Is the person using a curandero?

Treatment issues for Hispanic
Consumers
Hallucinations are natural in their
religion.
 Hearing the voice of a loved one or having
hallucinations might be an expectations
when celebrating the Day of the Dead.
 Hispanic families are patriarchal.


Hispanic Consumers and
The Day of the Dead
A man is dressed in a skeleton
costume to portray death
in a celebration of
Dia de los Muertos,
The Day of the Dead.
People visit the graves of their
dead relatives to honor them.

Native Americans

Treatment Issues for Native
American Consumers
 Impact of racism,unemployment,and poverty.
 Coping with reservation life and
assimilation in mainstream culture.
 Consider the obesity, diabetes,
hypertension, and alcoholism in adults
and fetal alcohol syndrome in children.
 High use of native healers in the Southwest.

African Americans

African Americans
from the Houston Chronicle, 1/23/03

There are 36.2 million Americans who
identify themselves as “black only.”
 37.7 million identify themselves as “black
and at least one other race.”
 11.5% of Texans are African Americans.


Treatment Issues for African
American
Assess for co-occurring substance use
disorders and alcoholism.
 Address complications of obesity,
hypertension, diabetes,congestive heart
failure, asthma, and cancer.
 Sickle cell anemia is another illness
specific to African Americans.


Treatment Issues for African
Americans
Matriarchy; Mom or grandmother are the
dominant family figures.
 Lack of male role models and intact
families.
 Extended family or the Church may be
supports.


Treatment Issues for African
Americans


There is discrimination within their own
group based on skin color, hair texture,
class, values, etc.

Treatment Issues for Asians

Asians rarely seek help until its very severe.
Asians have extremely low admissions to state hospitals.
Mental illness is considered shameful. It’s hidden.
Is an interpreter needed?

Treatment Issues for Asians
Focus on physical symptoms.
 Asians are sensitive to medication.
 Give ½ the standard dose.
 Asians may use traditional healers and
herbal medicine.
 Asians may “flush” when drinking
alcohol.


Asian Consumers

Acupuncture has been used to treat
pain, schizophrenia, depression, and addictions.

Treatment Issues for Asians
Asian Cultures are patriarchal.
 The males in the family have the authority.
 Asians are more formal and inhibited in
their social behavior.


Older Adults

Treatment Issues for Older
Adults
Are they aware they need help?

Treatment Issues for Older
Adults
Is their mental illness caused by medicine?
 Do their medical problems cause or
complicate their mental illness?
 Is there Elder Abuse?


Gay Men and Lesbian Women
May struggle with homophobia and“being in the
closet” at work and with their families.
Gay people may want marriage, children, partner
benefits, etc., but may endure legal barriers.

Gay and Lesbian Women
Gay people often have specific health
issues related to their sexual practices.
 HIV, AIDS and STD’s are still concerns
with Gay men.
 People may be grieving the death of a
partner or friends who’ve died from AIDS,
or coping with living with AIDS or being
HIV+ themselves.


Treatment Issues for Gay and
Lesbians
Explore childhood abuse issues and
Domestic Violence..
 Assess for substance use and alcoholism.
 Sex enhancing drug use may be common
among some gay men.


Physically Challenged
Can they get to treatment?
Deal with their frustration and depression
Re: their disability.
 Do they need vocational assistance?

Mentally Challenged

Treatment Issues of Mentally
Challenged
They need to have meaningful activity
and purpose in their lives.
 They need to feel acknowledged and
appreciated.
 They need safety, structure, and security.
 Lack of continuity can cause crisis!
 They may need vocational assistance.


Winona Ryder

December 12, 2001,
Winona Ryder shoplifted
$5,560.40 designer items
from Saks Fifth Avenue in
Beverley Hills.

Twice an Academy
Award Nominated
actress

She had the following 8 drugs in
her possession:
Liquid demerol
 Liquid Diazepam
 Vicodin
 Percodan
 Valium
 Morphine sulfate
 Endocet (containing Oxycodone)


Patterns of Drug Use are highly
Regional.
 Drugs,

routes of administration, street
names, patterns of use, and drug
combinations may differ greatly, not
only between individuals from
different cultures, but different parts
of the country or even different parts
of the city.

Drugs of Choice
Native Americans-alcohol
 Asians-gambling, work
 Gay Men-stimulants, amyl nitrate, ecstasy
 “Rich”-prescription drugs, Internet porn
 M.D.’s –Vicodin


Drugs of Choice
Young adults-marijuana, cigarettes
 Geriatrics-alcohol, pills
 Sex Workers-crack cocaine, IV speedballs
 Screen mentally retarded for abuse too!


How Do We Best Serve Our
Consumers?




Examine own stereotypes.
Build trust.
Use People First language!

How do we best serve our
consumers?
Pronounce the person’s name correctly.
 Get an interpreter, if necessary.
 Educate yourself from the consumer, his
family, co-workers, etc.
 Remember differences do matter!



Slide 39

Cultural Competence
Integrating Differences
into Community Services

Objectives
Understand Stigma.
 Understand Culture Competency.
 Learn Culturally competent care for
people with Mental Health, Mental
Retardation and Addictions.


We live in an world
which often separates us.
Racism
 Sexism
 Ageism
 Feminism
 Classism
 Atheism


“Different” people are
“Stigmatized”

Mentally retarded inmates in a sanitorium in Germany

Stigma
Definitions from the U. of Chicago PSR Training Manual

“Stigmas are negative attitudes about a
group that lead to depriving them of
some fair opportunities.”

Stigma is related to…..
Stereotypes
Prejudice
Discrimination

Stereotypes
from The Asian Health Coalition of Illinois

Stereotypes are exaggerated beliefs
or fixed ideas about a person or
group which is held by people and
sustained by selective perception and
selective forgetting.

Prejudice
from The Asian Health Coalition of Illinois

Prejudice is a preconceived idea or
negative attitude formed before the
facts are known and sustained over
generalizations. A bias without
reason, resisting all evidence…

Discrimination
from The Asian Health Coalition of Illinois

Discrimination refers to treatment in
favor or against a person based on
the group to which that person
belongs and not on merit.

Stigmatized People…..
Experience being stereotyped and
are often the object of
discrimination and prejudice.

People are often stigmatized by:













Mental Illness
Mental Retardation
Physical Disability (including blindness, deafness)
Alcoholism /and or Drug Addiction
HIV or AIDS, Cancer or other terminal illnesses
Criminal behavior
Poverty
Alternative Lifestyles/sexual orientation
Wheelchair bound
Gender
Obesity

All our Consumers belong to
stigmatized groups!

Stigmatized People
Consumers and their families
can’t navigate the bureaucracy
even if resources are there.
It’s too frustrating!

Use People First Language
“I am more than my
illness….Don’t call me
“the schizophrenic,
“the addict” or
“the retard.”

As human beings, we have many
similarities…..
But, who we really are, is often
derived from our original family of origin
and our current lifestyle.

The Bottom Line:
People are different, even within
their own culture!
These differences matter when
planning and providing services.

National Mental Health
Association
“For Mental Health consumers, both
access to the services and the effectiveness
of the care they receive are greatly affected
by the degree to which the delivery system
is“culturally competent.”

Some important definitions
Related to Cultural Competency

Culture

from King,et. al

The Office of Special Programs, U.S. Dept. of Education

“The integrated patterns of human
behavior that includes thoughts,
communications, actions, customs,
beliefs,values, and institutions of
racial, ethnic, religious, or social
groups.”

Cultural Sensitivity
An awareness and respect of a
person’s cultural beliefs and
values.
Culhane-Pera, et .al

Cultural Competency
 Skills

(that translate into)
 Behaviors, Practices, Attitudes, and
 Policies
That enable an individual, agency, or
system to effectively serve culturally
diverse communities.
from The Asian Health Coalition of Illinois

Here at Hill Country MHDDC
Consumers are very diverse in their
language and culture.

61% of our Consumers are
Caucasian Americans
Many have German
backgrounds.

Our Consumers are …..

n
1% NativeAmerican

33% Hispanic
1% Asian

3% African
American

1% are “Others”

Consumers Have Many
Different Lifestyles

Lifestyles

They have many different
beliefs.

Can We Communicate?
Think Language first!
 Do we need an interpreter?
 Communicate respectfully.
 Be sensitive to the consumer and the family.
 Consider your dress, tone of voice, eye contact,
location, seating arrangement, privacy, etc.


Is our approach culturally
appropriate?
“What do you call your problem?”
“What name does it have?”
“What do you think caused your problem?”
“Why do you think it started when it did?”
From Arthur Kleinman’s question protocol in“Culture,Illness, and Care:
Clinical Lessons from Anthropologic and Cross Cultural Research”,
Ann.Intern.Med. 1978:Vol.88, pg.251-258

Important Issues to Consider…





Impact of religion.
How are women, men, elders, and children
treated in their culture?
Is there domestic violence?
Ethnic minorities generally underutilize
outpatient services, although African-Americans
are over-represented in inpatient setting.

Diagnosis






Minorities with Bipolar Disorder are often
diagnosed with schizophrenia. (Mukherjee,et al)
African Americans are over diagnosed with
schizophrenia and under diagnosed with mood
disorders. (Bell )
A mental health consumer’s addictions may not
be treated.
The elderly may not be assessed for substance
abuse or alcoholism.

Diagnosis
A person with a primary addiction problem
might not be treated for a co-occurring mental
illness.
 Learning disabilities may not be identified in
individuals with mental illness or substance
abuse.
 A person with mental retardation may not be
treated for mental illness or substance abuse.


Diagnosis
Post Traumatic Stress Disorder is often
undiagnosed in people suffering from
Domestic Abuse or other trauma.
 Children who are witnessing or are
victims of domestic abuse or another
trauma, may be misdiagnosed with
Attention Deficit Hyperactivity Disorder.


Medication Differences





Asians and Hispanics need lower doses of antipsychotics.
African Americans use the same doses of antipsychotics, but lower doses of lithium.
The elderly need lower dosages of medications.
Thus, metabolism of drugs varies with age and
ethnicity and is critical in prescribing
medications.

From “Making Room for Culture in Psychiatry” by Lin, et al.

Pain Tolerance
Men and women tolerate pain differently.
 Cultures tolerate pain differently.
 People with addictions develop a
hypersensitivity to pain.
 In certain cultures, self-inflicted pain is a
part of a religious experience.


Religion





Religious beliefs shape how the world is viewed.
Is illness a punishment? The devil’s work? An
evil spell? Bad karma?
For Hispanics, the curandero is a trusted healer.
For Lakota Sioux, the ritual Vision Quest,
praying and fasting at a holy site is life
changing.

Remember there are as many
differences
Between individuals in the same
culture as there are between
individuals in different cultures!

Two African American
families, one lesbian
and the other, multi-racial.

German Consumers
Suggestions from our Gillespie County MH staff

What generation German?
 Would they feel more comfortable
speaking in German?


A consumer reacting to internal stimuli.

German Consumers
Suggestions from our Gillespie MHC staff in Fredericksburg

They may be resistant to seeking
mental services.
They may be reluctant to take medication.
They may “keep things within the family.”
They are concerned about the stigma.

German Consumers
They may feel it’s a character flaw or a
disgrace.
 They are very concerned about
confidentiality.
 Drinking alcohol is an accepted part of
their culture.
 Teen drinking may be acceptable in their
family.


Hispanic Consumers
from the U.S. Census, 1/23/03 Houston Chronicle

Hispanics are the largest minority group in
the U.S. with 37 million people.
 Texas is approximately 32 percent
Hispanic
 11.5 % African American,
 3.3% Other
 53.1% Anglo


Treatment Issues for Hispanic
Consumers
Do we need an interpreter?
 Is the person Tejano or from Mexico?
What generation Hispanic?
Is the person using a curandero?

Treatment issues for Hispanic
Consumers
Hallucinations are natural in their
religion.
 Hearing the voice of a loved one or having
hallucinations might be an expectations
when celebrating the Day of the Dead.
 Hispanic families are patriarchal.


Hispanic Consumers and
The Day of the Dead
A man is dressed in a skeleton
costume to portray death
in a celebration of
Dia de los Muertos,
The Day of the Dead.
People visit the graves of their
dead relatives to honor them.

Native Americans

Treatment Issues for Native
American Consumers
 Impact of racism,unemployment,and poverty.
 Coping with reservation life and
assimilation in mainstream culture.
 Consider the obesity, diabetes,
hypertension, and alcoholism in adults
and fetal alcohol syndrome in children.
 High use of native healers in the Southwest.

African Americans

African Americans
from the Houston Chronicle, 1/23/03

There are 36.2 million Americans who
identify themselves as “black only.”
 37.7 million identify themselves as “black
and at least one other race.”
 11.5% of Texans are African Americans.


Treatment Issues for African
American
Assess for co-occurring substance use
disorders and alcoholism.
 Address complications of obesity,
hypertension, diabetes,congestive heart
failure, asthma, and cancer.
 Sickle cell anemia is another illness
specific to African Americans.


Treatment Issues for African
Americans
Matriarchy; Mom or grandmother are the
dominant family figures.
 Lack of male role models and intact
families.
 Extended family or the Church may be
supports.


Treatment Issues for African
Americans


There is discrimination within their own
group based on skin color, hair texture,
class, values, etc.

Treatment Issues for Asians

Asians rarely seek help until its very severe.
Asians have extremely low admissions to state hospitals.
Mental illness is considered shameful. It’s hidden.
Is an interpreter needed?

Treatment Issues for Asians
Focus on physical symptoms.
 Asians are sensitive to medication.
 Give ½ the standard dose.
 Asians may use traditional healers and
herbal medicine.
 Asians may “flush” when drinking
alcohol.


Asian Consumers

Acupuncture has been used to treat
pain, schizophrenia, depression, and addictions.

Treatment Issues for Asians
Asian Cultures are patriarchal.
 The males in the family have the authority.
 Asians are more formal and inhibited in
their social behavior.


Older Adults

Treatment Issues for Older
Adults
Are they aware they need help?

Treatment Issues for Older
Adults
Is their mental illness caused by medicine?
 Do their medical problems cause or
complicate their mental illness?
 Is there Elder Abuse?


Gay Men and Lesbian Women
May struggle with homophobia and“being in the
closet” at work and with their families.
Gay people may want marriage, children, partner
benefits, etc., but may endure legal barriers.

Gay and Lesbian Women
Gay people often have specific health
issues related to their sexual practices.
 HIV, AIDS and STD’s are still concerns
with Gay men.
 People may be grieving the death of a
partner or friends who’ve died from AIDS,
or coping with living with AIDS or being
HIV+ themselves.


Treatment Issues for Gay and
Lesbians
Explore childhood abuse issues and
Domestic Violence..
 Assess for substance use and alcoholism.
 Sex enhancing drug use may be common
among some gay men.


Physically Challenged
Can they get to treatment?
Deal with their frustration and depression
Re: their disability.
 Do they need vocational assistance?

Mentally Challenged

Treatment Issues of Mentally
Challenged
They need to have meaningful activity
and purpose in their lives.
 They need to feel acknowledged and
appreciated.
 They need safety, structure, and security.
 Lack of continuity can cause crisis!
 They may need vocational assistance.


Winona Ryder

December 12, 2001,
Winona Ryder shoplifted
$5,560.40 designer items
from Saks Fifth Avenue in
Beverley Hills.

Twice an Academy
Award Nominated
actress

She had the following 8 drugs in
her possession:
Liquid demerol
 Liquid Diazepam
 Vicodin
 Percodan
 Valium
 Morphine sulfate
 Endocet (containing Oxycodone)


Patterns of Drug Use are highly
Regional.
 Drugs,

routes of administration, street
names, patterns of use, and drug
combinations may differ greatly, not
only between individuals from
different cultures, but different parts
of the country or even different parts
of the city.

Drugs of Choice
Native Americans-alcohol
 Asians-gambling, work
 Gay Men-stimulants, amyl nitrate, ecstasy
 “Rich”-prescription drugs, Internet porn
 M.D.’s –Vicodin


Drugs of Choice
Young adults-marijuana, cigarettes
 Geriatrics-alcohol, pills
 Sex Workers-crack cocaine, IV speedballs
 Screen mentally retarded for abuse too!


How Do We Best Serve Our
Consumers?




Examine own stereotypes.
Build trust.
Use People First language!

How do we best serve our
consumers?
Pronounce the person’s name correctly.
 Get an interpreter, if necessary.
 Educate yourself from the consumer, his
family, co-workers, etc.
 Remember differences do matter!



Slide 40

Cultural Competence
Integrating Differences
into Community Services

Objectives
Understand Stigma.
 Understand Culture Competency.
 Learn Culturally competent care for
people with Mental Health, Mental
Retardation and Addictions.


We live in an world
which often separates us.
Racism
 Sexism
 Ageism
 Feminism
 Classism
 Atheism


“Different” people are
“Stigmatized”

Mentally retarded inmates in a sanitorium in Germany

Stigma
Definitions from the U. of Chicago PSR Training Manual

“Stigmas are negative attitudes about a
group that lead to depriving them of
some fair opportunities.”

Stigma is related to…..
Stereotypes
Prejudice
Discrimination

Stereotypes
from The Asian Health Coalition of Illinois

Stereotypes are exaggerated beliefs
or fixed ideas about a person or
group which is held by people and
sustained by selective perception and
selective forgetting.

Prejudice
from The Asian Health Coalition of Illinois

Prejudice is a preconceived idea or
negative attitude formed before the
facts are known and sustained over
generalizations. A bias without
reason, resisting all evidence…

Discrimination
from The Asian Health Coalition of Illinois

Discrimination refers to treatment in
favor or against a person based on
the group to which that person
belongs and not on merit.

Stigmatized People…..
Experience being stereotyped and
are often the object of
discrimination and prejudice.

People are often stigmatized by:













Mental Illness
Mental Retardation
Physical Disability (including blindness, deafness)
Alcoholism /and or Drug Addiction
HIV or AIDS, Cancer or other terminal illnesses
Criminal behavior
Poverty
Alternative Lifestyles/sexual orientation
Wheelchair bound
Gender
Obesity

All our Consumers belong to
stigmatized groups!

Stigmatized People
Consumers and their families
can’t navigate the bureaucracy
even if resources are there.
It’s too frustrating!

Use People First Language
“I am more than my
illness….Don’t call me
“the schizophrenic,
“the addict” or
“the retard.”

As human beings, we have many
similarities…..
But, who we really are, is often
derived from our original family of origin
and our current lifestyle.

The Bottom Line:
People are different, even within
their own culture!
These differences matter when
planning and providing services.

National Mental Health
Association
“For Mental Health consumers, both
access to the services and the effectiveness
of the care they receive are greatly affected
by the degree to which the delivery system
is“culturally competent.”

Some important definitions
Related to Cultural Competency

Culture

from King,et. al

The Office of Special Programs, U.S. Dept. of Education

“The integrated patterns of human
behavior that includes thoughts,
communications, actions, customs,
beliefs,values, and institutions of
racial, ethnic, religious, or social
groups.”

Cultural Sensitivity
An awareness and respect of a
person’s cultural beliefs and
values.
Culhane-Pera, et .al

Cultural Competency
 Skills

(that translate into)
 Behaviors, Practices, Attitudes, and
 Policies
That enable an individual, agency, or
system to effectively serve culturally
diverse communities.
from The Asian Health Coalition of Illinois

Here at Hill Country MHDDC
Consumers are very diverse in their
language and culture.

61% of our Consumers are
Caucasian Americans
Many have German
backgrounds.

Our Consumers are …..

n
1% NativeAmerican

33% Hispanic
1% Asian

3% African
American

1% are “Others”

Consumers Have Many
Different Lifestyles

Lifestyles

They have many different
beliefs.

Can We Communicate?
Think Language first!
 Do we need an interpreter?
 Communicate respectfully.
 Be sensitive to the consumer and the family.
 Consider your dress, tone of voice, eye contact,
location, seating arrangement, privacy, etc.


Is our approach culturally
appropriate?
“What do you call your problem?”
“What name does it have?”
“What do you think caused your problem?”
“Why do you think it started when it did?”
From Arthur Kleinman’s question protocol in“Culture,Illness, and Care:
Clinical Lessons from Anthropologic and Cross Cultural Research”,
Ann.Intern.Med. 1978:Vol.88, pg.251-258

Important Issues to Consider…





Impact of religion.
How are women, men, elders, and children
treated in their culture?
Is there domestic violence?
Ethnic minorities generally underutilize
outpatient services, although African-Americans
are over-represented in inpatient setting.

Diagnosis






Minorities with Bipolar Disorder are often
diagnosed with schizophrenia. (Mukherjee,et al)
African Americans are over diagnosed with
schizophrenia and under diagnosed with mood
disorders. (Bell )
A mental health consumer’s addictions may not
be treated.
The elderly may not be assessed for substance
abuse or alcoholism.

Diagnosis
A person with a primary addiction problem
might not be treated for a co-occurring mental
illness.
 Learning disabilities may not be identified in
individuals with mental illness or substance
abuse.
 A person with mental retardation may not be
treated for mental illness or substance abuse.


Diagnosis
Post Traumatic Stress Disorder is often
undiagnosed in people suffering from
Domestic Abuse or other trauma.
 Children who are witnessing or are
victims of domestic abuse or another
trauma, may be misdiagnosed with
Attention Deficit Hyperactivity Disorder.


Medication Differences





Asians and Hispanics need lower doses of antipsychotics.
African Americans use the same doses of antipsychotics, but lower doses of lithium.
The elderly need lower dosages of medications.
Thus, metabolism of drugs varies with age and
ethnicity and is critical in prescribing
medications.

From “Making Room for Culture in Psychiatry” by Lin, et al.

Pain Tolerance
Men and women tolerate pain differently.
 Cultures tolerate pain differently.
 People with addictions develop a
hypersensitivity to pain.
 In certain cultures, self-inflicted pain is a
part of a religious experience.


Religion





Religious beliefs shape how the world is viewed.
Is illness a punishment? The devil’s work? An
evil spell? Bad karma?
For Hispanics, the curandero is a trusted healer.
For Lakota Sioux, the ritual Vision Quest,
praying and fasting at a holy site is life
changing.

Remember there are as many
differences
Between individuals in the same
culture as there are between
individuals in different cultures!

Two African American
families, one lesbian
and the other, multi-racial.

German Consumers
Suggestions from our Gillespie County MH staff

What generation German?
 Would they feel more comfortable
speaking in German?


A consumer reacting to internal stimuli.

German Consumers
Suggestions from our Gillespie MHC staff in Fredericksburg

They may be resistant to seeking
mental services.
They may be reluctant to take medication.
They may “keep things within the family.”
They are concerned about the stigma.

German Consumers
They may feel it’s a character flaw or a
disgrace.
 They are very concerned about
confidentiality.
 Drinking alcohol is an accepted part of
their culture.
 Teen drinking may be acceptable in their
family.


Hispanic Consumers
from the U.S. Census, 1/23/03 Houston Chronicle

Hispanics are the largest minority group in
the U.S. with 37 million people.
 Texas is approximately 32 percent
Hispanic
 11.5 % African American,
 3.3% Other
 53.1% Anglo


Treatment Issues for Hispanic
Consumers
Do we need an interpreter?
 Is the person Tejano or from Mexico?
What generation Hispanic?
Is the person using a curandero?

Treatment issues for Hispanic
Consumers
Hallucinations are natural in their
religion.
 Hearing the voice of a loved one or having
hallucinations might be an expectations
when celebrating the Day of the Dead.
 Hispanic families are patriarchal.


Hispanic Consumers and
The Day of the Dead
A man is dressed in a skeleton
costume to portray death
in a celebration of
Dia de los Muertos,
The Day of the Dead.
People visit the graves of their
dead relatives to honor them.

Native Americans

Treatment Issues for Native
American Consumers
 Impact of racism,unemployment,and poverty.
 Coping with reservation life and
assimilation in mainstream culture.
 Consider the obesity, diabetes,
hypertension, and alcoholism in adults
and fetal alcohol syndrome in children.
 High use of native healers in the Southwest.

African Americans

African Americans
from the Houston Chronicle, 1/23/03

There are 36.2 million Americans who
identify themselves as “black only.”
 37.7 million identify themselves as “black
and at least one other race.”
 11.5% of Texans are African Americans.


Treatment Issues for African
American
Assess for co-occurring substance use
disorders and alcoholism.
 Address complications of obesity,
hypertension, diabetes,congestive heart
failure, asthma, and cancer.
 Sickle cell anemia is another illness
specific to African Americans.


Treatment Issues for African
Americans
Matriarchy; Mom or grandmother are the
dominant family figures.
 Lack of male role models and intact
families.
 Extended family or the Church may be
supports.


Treatment Issues for African
Americans


There is discrimination within their own
group based on skin color, hair texture,
class, values, etc.

Treatment Issues for Asians

Asians rarely seek help until its very severe.
Asians have extremely low admissions to state hospitals.
Mental illness is considered shameful. It’s hidden.
Is an interpreter needed?

Treatment Issues for Asians
Focus on physical symptoms.
 Asians are sensitive to medication.
 Give ½ the standard dose.
 Asians may use traditional healers and
herbal medicine.
 Asians may “flush” when drinking
alcohol.


Asian Consumers

Acupuncture has been used to treat
pain, schizophrenia, depression, and addictions.

Treatment Issues for Asians
Asian Cultures are patriarchal.
 The males in the family have the authority.
 Asians are more formal and inhibited in
their social behavior.


Older Adults

Treatment Issues for Older
Adults
Are they aware they need help?

Treatment Issues for Older
Adults
Is their mental illness caused by medicine?
 Do their medical problems cause or
complicate their mental illness?
 Is there Elder Abuse?


Gay Men and Lesbian Women
May struggle with homophobia and“being in the
closet” at work and with their families.
Gay people may want marriage, children, partner
benefits, etc., but may endure legal barriers.

Gay and Lesbian Women
Gay people often have specific health
issues related to their sexual practices.
 HIV, AIDS and STD’s are still concerns
with Gay men.
 People may be grieving the death of a
partner or friends who’ve died from AIDS,
or coping with living with AIDS or being
HIV+ themselves.


Treatment Issues for Gay and
Lesbians
Explore childhood abuse issues and
Domestic Violence..
 Assess for substance use and alcoholism.
 Sex enhancing drug use may be common
among some gay men.


Physically Challenged
Can they get to treatment?
Deal with their frustration and depression
Re: their disability.
 Do they need vocational assistance?

Mentally Challenged

Treatment Issues of Mentally
Challenged
They need to have meaningful activity
and purpose in their lives.
 They need to feel acknowledged and
appreciated.
 They need safety, structure, and security.
 Lack of continuity can cause crisis!
 They may need vocational assistance.


Winona Ryder

December 12, 2001,
Winona Ryder shoplifted
$5,560.40 designer items
from Saks Fifth Avenue in
Beverley Hills.

Twice an Academy
Award Nominated
actress

She had the following 8 drugs in
her possession:
Liquid demerol
 Liquid Diazepam
 Vicodin
 Percodan
 Valium
 Morphine sulfate
 Endocet (containing Oxycodone)


Patterns of Drug Use are highly
Regional.
 Drugs,

routes of administration, street
names, patterns of use, and drug
combinations may differ greatly, not
only between individuals from
different cultures, but different parts
of the country or even different parts
of the city.

Drugs of Choice
Native Americans-alcohol
 Asians-gambling, work
 Gay Men-stimulants, amyl nitrate, ecstasy
 “Rich”-prescription drugs, Internet porn
 M.D.’s –Vicodin


Drugs of Choice
Young adults-marijuana, cigarettes
 Geriatrics-alcohol, pills
 Sex Workers-crack cocaine, IV speedballs
 Screen mentally retarded for abuse too!


How Do We Best Serve Our
Consumers?




Examine own stereotypes.
Build trust.
Use People First language!

How do we best serve our
consumers?
Pronounce the person’s name correctly.
 Get an interpreter, if necessary.
 Educate yourself from the consumer, his
family, co-workers, etc.
 Remember differences do matter!



Slide 41

Cultural Competence
Integrating Differences
into Community Services

Objectives
Understand Stigma.
 Understand Culture Competency.
 Learn Culturally competent care for
people with Mental Health, Mental
Retardation and Addictions.


We live in an world
which often separates us.
Racism
 Sexism
 Ageism
 Feminism
 Classism
 Atheism


“Different” people are
“Stigmatized”

Mentally retarded inmates in a sanitorium in Germany

Stigma
Definitions from the U. of Chicago PSR Training Manual

“Stigmas are negative attitudes about a
group that lead to depriving them of
some fair opportunities.”

Stigma is related to…..
Stereotypes
Prejudice
Discrimination

Stereotypes
from The Asian Health Coalition of Illinois

Stereotypes are exaggerated beliefs
or fixed ideas about a person or
group which is held by people and
sustained by selective perception and
selective forgetting.

Prejudice
from The Asian Health Coalition of Illinois

Prejudice is a preconceived idea or
negative attitude formed before the
facts are known and sustained over
generalizations. A bias without
reason, resisting all evidence…

Discrimination
from The Asian Health Coalition of Illinois

Discrimination refers to treatment in
favor or against a person based on
the group to which that person
belongs and not on merit.

Stigmatized People…..
Experience being stereotyped and
are often the object of
discrimination and prejudice.

People are often stigmatized by:













Mental Illness
Mental Retardation
Physical Disability (including blindness, deafness)
Alcoholism /and or Drug Addiction
HIV or AIDS, Cancer or other terminal illnesses
Criminal behavior
Poverty
Alternative Lifestyles/sexual orientation
Wheelchair bound
Gender
Obesity

All our Consumers belong to
stigmatized groups!

Stigmatized People
Consumers and their families
can’t navigate the bureaucracy
even if resources are there.
It’s too frustrating!

Use People First Language
“I am more than my
illness….Don’t call me
“the schizophrenic,
“the addict” or
“the retard.”

As human beings, we have many
similarities…..
But, who we really are, is often
derived from our original family of origin
and our current lifestyle.

The Bottom Line:
People are different, even within
their own culture!
These differences matter when
planning and providing services.

National Mental Health
Association
“For Mental Health consumers, both
access to the services and the effectiveness
of the care they receive are greatly affected
by the degree to which the delivery system
is“culturally competent.”

Some important definitions
Related to Cultural Competency

Culture

from King,et. al

The Office of Special Programs, U.S. Dept. of Education

“The integrated patterns of human
behavior that includes thoughts,
communications, actions, customs,
beliefs,values, and institutions of
racial, ethnic, religious, or social
groups.”

Cultural Sensitivity
An awareness and respect of a
person’s cultural beliefs and
values.
Culhane-Pera, et .al

Cultural Competency
 Skills

(that translate into)
 Behaviors, Practices, Attitudes, and
 Policies
That enable an individual, agency, or
system to effectively serve culturally
diverse communities.
from The Asian Health Coalition of Illinois

Here at Hill Country MHDDC
Consumers are very diverse in their
language and culture.

61% of our Consumers are
Caucasian Americans
Many have German
backgrounds.

Our Consumers are …..

n
1% NativeAmerican

33% Hispanic
1% Asian

3% African
American

1% are “Others”

Consumers Have Many
Different Lifestyles

Lifestyles

They have many different
beliefs.

Can We Communicate?
Think Language first!
 Do we need an interpreter?
 Communicate respectfully.
 Be sensitive to the consumer and the family.
 Consider your dress, tone of voice, eye contact,
location, seating arrangement, privacy, etc.


Is our approach culturally
appropriate?
“What do you call your problem?”
“What name does it have?”
“What do you think caused your problem?”
“Why do you think it started when it did?”
From Arthur Kleinman’s question protocol in“Culture,Illness, and Care:
Clinical Lessons from Anthropologic and Cross Cultural Research”,
Ann.Intern.Med. 1978:Vol.88, pg.251-258

Important Issues to Consider…





Impact of religion.
How are women, men, elders, and children
treated in their culture?
Is there domestic violence?
Ethnic minorities generally underutilize
outpatient services, although African-Americans
are over-represented in inpatient setting.

Diagnosis






Minorities with Bipolar Disorder are often
diagnosed with schizophrenia. (Mukherjee,et al)
African Americans are over diagnosed with
schizophrenia and under diagnosed with mood
disorders. (Bell )
A mental health consumer’s addictions may not
be treated.
The elderly may not be assessed for substance
abuse or alcoholism.

Diagnosis
A person with a primary addiction problem
might not be treated for a co-occurring mental
illness.
 Learning disabilities may not be identified in
individuals with mental illness or substance
abuse.
 A person with mental retardation may not be
treated for mental illness or substance abuse.


Diagnosis
Post Traumatic Stress Disorder is often
undiagnosed in people suffering from
Domestic Abuse or other trauma.
 Children who are witnessing or are
victims of domestic abuse or another
trauma, may be misdiagnosed with
Attention Deficit Hyperactivity Disorder.


Medication Differences





Asians and Hispanics need lower doses of antipsychotics.
African Americans use the same doses of antipsychotics, but lower doses of lithium.
The elderly need lower dosages of medications.
Thus, metabolism of drugs varies with age and
ethnicity and is critical in prescribing
medications.

From “Making Room for Culture in Psychiatry” by Lin, et al.

Pain Tolerance
Men and women tolerate pain differently.
 Cultures tolerate pain differently.
 People with addictions develop a
hypersensitivity to pain.
 In certain cultures, self-inflicted pain is a
part of a religious experience.


Religion





Religious beliefs shape how the world is viewed.
Is illness a punishment? The devil’s work? An
evil spell? Bad karma?
For Hispanics, the curandero is a trusted healer.
For Lakota Sioux, the ritual Vision Quest,
praying and fasting at a holy site is life
changing.

Remember there are as many
differences
Between individuals in the same
culture as there are between
individuals in different cultures!

Two African American
families, one lesbian
and the other, multi-racial.

German Consumers
Suggestions from our Gillespie County MH staff

What generation German?
 Would they feel more comfortable
speaking in German?


A consumer reacting to internal stimuli.

German Consumers
Suggestions from our Gillespie MHC staff in Fredericksburg

They may be resistant to seeking
mental services.
They may be reluctant to take medication.
They may “keep things within the family.”
They are concerned about the stigma.

German Consumers
They may feel it’s a character flaw or a
disgrace.
 They are very concerned about
confidentiality.
 Drinking alcohol is an accepted part of
their culture.
 Teen drinking may be acceptable in their
family.


Hispanic Consumers
from the U.S. Census, 1/23/03 Houston Chronicle

Hispanics are the largest minority group in
the U.S. with 37 million people.
 Texas is approximately 32 percent
Hispanic
 11.5 % African American,
 3.3% Other
 53.1% Anglo


Treatment Issues for Hispanic
Consumers
Do we need an interpreter?
 Is the person Tejano or from Mexico?
What generation Hispanic?
Is the person using a curandero?

Treatment issues for Hispanic
Consumers
Hallucinations are natural in their
religion.
 Hearing the voice of a loved one or having
hallucinations might be an expectations
when celebrating the Day of the Dead.
 Hispanic families are patriarchal.


Hispanic Consumers and
The Day of the Dead
A man is dressed in a skeleton
costume to portray death
in a celebration of
Dia de los Muertos,
The Day of the Dead.
People visit the graves of their
dead relatives to honor them.

Native Americans

Treatment Issues for Native
American Consumers
 Impact of racism,unemployment,and poverty.
 Coping with reservation life and
assimilation in mainstream culture.
 Consider the obesity, diabetes,
hypertension, and alcoholism in adults
and fetal alcohol syndrome in children.
 High use of native healers in the Southwest.

African Americans

African Americans
from the Houston Chronicle, 1/23/03

There are 36.2 million Americans who
identify themselves as “black only.”
 37.7 million identify themselves as “black
and at least one other race.”
 11.5% of Texans are African Americans.


Treatment Issues for African
American
Assess for co-occurring substance use
disorders and alcoholism.
 Address complications of obesity,
hypertension, diabetes,congestive heart
failure, asthma, and cancer.
 Sickle cell anemia is another illness
specific to African Americans.


Treatment Issues for African
Americans
Matriarchy; Mom or grandmother are the
dominant family figures.
 Lack of male role models and intact
families.
 Extended family or the Church may be
supports.


Treatment Issues for African
Americans


There is discrimination within their own
group based on skin color, hair texture,
class, values, etc.

Treatment Issues for Asians

Asians rarely seek help until its very severe.
Asians have extremely low admissions to state hospitals.
Mental illness is considered shameful. It’s hidden.
Is an interpreter needed?

Treatment Issues for Asians
Focus on physical symptoms.
 Asians are sensitive to medication.
 Give ½ the standard dose.
 Asians may use traditional healers and
herbal medicine.
 Asians may “flush” when drinking
alcohol.


Asian Consumers

Acupuncture has been used to treat
pain, schizophrenia, depression, and addictions.

Treatment Issues for Asians
Asian Cultures are patriarchal.
 The males in the family have the authority.
 Asians are more formal and inhibited in
their social behavior.


Older Adults

Treatment Issues for Older
Adults
Are they aware they need help?

Treatment Issues for Older
Adults
Is their mental illness caused by medicine?
 Do their medical problems cause or
complicate their mental illness?
 Is there Elder Abuse?


Gay Men and Lesbian Women
May struggle with homophobia and“being in the
closet” at work and with their families.
Gay people may want marriage, children, partner
benefits, etc., but may endure legal barriers.

Gay and Lesbian Women
Gay people often have specific health
issues related to their sexual practices.
 HIV, AIDS and STD’s are still concerns
with Gay men.
 People may be grieving the death of a
partner or friends who’ve died from AIDS,
or coping with living with AIDS or being
HIV+ themselves.


Treatment Issues for Gay and
Lesbians
Explore childhood abuse issues and
Domestic Violence..
 Assess for substance use and alcoholism.
 Sex enhancing drug use may be common
among some gay men.


Physically Challenged
Can they get to treatment?
Deal with their frustration and depression
Re: their disability.
 Do they need vocational assistance?

Mentally Challenged

Treatment Issues of Mentally
Challenged
They need to have meaningful activity
and purpose in their lives.
 They need to feel acknowledged and
appreciated.
 They need safety, structure, and security.
 Lack of continuity can cause crisis!
 They may need vocational assistance.


Winona Ryder

December 12, 2001,
Winona Ryder shoplifted
$5,560.40 designer items
from Saks Fifth Avenue in
Beverley Hills.

Twice an Academy
Award Nominated
actress

She had the following 8 drugs in
her possession:
Liquid demerol
 Liquid Diazepam
 Vicodin
 Percodan
 Valium
 Morphine sulfate
 Endocet (containing Oxycodone)


Patterns of Drug Use are highly
Regional.
 Drugs,

routes of administration, street
names, patterns of use, and drug
combinations may differ greatly, not
only between individuals from
different cultures, but different parts
of the country or even different parts
of the city.

Drugs of Choice
Native Americans-alcohol
 Asians-gambling, work
 Gay Men-stimulants, amyl nitrate, ecstasy
 “Rich”-prescription drugs, Internet porn
 M.D.’s –Vicodin


Drugs of Choice
Young adults-marijuana, cigarettes
 Geriatrics-alcohol, pills
 Sex Workers-crack cocaine, IV speedballs
 Screen mentally retarded for abuse too!


How Do We Best Serve Our
Consumers?




Examine own stereotypes.
Build trust.
Use People First language!

How do we best serve our
consumers?
Pronounce the person’s name correctly.
 Get an interpreter, if necessary.
 Educate yourself from the consumer, his
family, co-workers, etc.
 Remember differences do matter!



Slide 42

Cultural Competence
Integrating Differences
into Community Services

Objectives
Understand Stigma.
 Understand Culture Competency.
 Learn Culturally competent care for
people with Mental Health, Mental
Retardation and Addictions.


We live in an world
which often separates us.
Racism
 Sexism
 Ageism
 Feminism
 Classism
 Atheism


“Different” people are
“Stigmatized”

Mentally retarded inmates in a sanitorium in Germany

Stigma
Definitions from the U. of Chicago PSR Training Manual

“Stigmas are negative attitudes about a
group that lead to depriving them of
some fair opportunities.”

Stigma is related to…..
Stereotypes
Prejudice
Discrimination

Stereotypes
from The Asian Health Coalition of Illinois

Stereotypes are exaggerated beliefs
or fixed ideas about a person or
group which is held by people and
sustained by selective perception and
selective forgetting.

Prejudice
from The Asian Health Coalition of Illinois

Prejudice is a preconceived idea or
negative attitude formed before the
facts are known and sustained over
generalizations. A bias without
reason, resisting all evidence…

Discrimination
from The Asian Health Coalition of Illinois

Discrimination refers to treatment in
favor or against a person based on
the group to which that person
belongs and not on merit.

Stigmatized People…..
Experience being stereotyped and
are often the object of
discrimination and prejudice.

People are often stigmatized by:













Mental Illness
Mental Retardation
Physical Disability (including blindness, deafness)
Alcoholism /and or Drug Addiction
HIV or AIDS, Cancer or other terminal illnesses
Criminal behavior
Poverty
Alternative Lifestyles/sexual orientation
Wheelchair bound
Gender
Obesity

All our Consumers belong to
stigmatized groups!

Stigmatized People
Consumers and their families
can’t navigate the bureaucracy
even if resources are there.
It’s too frustrating!

Use People First Language
“I am more than my
illness….Don’t call me
“the schizophrenic,
“the addict” or
“the retard.”

As human beings, we have many
similarities…..
But, who we really are, is often
derived from our original family of origin
and our current lifestyle.

The Bottom Line:
People are different, even within
their own culture!
These differences matter when
planning and providing services.

National Mental Health
Association
“For Mental Health consumers, both
access to the services and the effectiveness
of the care they receive are greatly affected
by the degree to which the delivery system
is“culturally competent.”

Some important definitions
Related to Cultural Competency

Culture

from King,et. al

The Office of Special Programs, U.S. Dept. of Education

“The integrated patterns of human
behavior that includes thoughts,
communications, actions, customs,
beliefs,values, and institutions of
racial, ethnic, religious, or social
groups.”

Cultural Sensitivity
An awareness and respect of a
person’s cultural beliefs and
values.
Culhane-Pera, et .al

Cultural Competency
 Skills

(that translate into)
 Behaviors, Practices, Attitudes, and
 Policies
That enable an individual, agency, or
system to effectively serve culturally
diverse communities.
from The Asian Health Coalition of Illinois

Here at Hill Country MHDDC
Consumers are very diverse in their
language and culture.

61% of our Consumers are
Caucasian Americans
Many have German
backgrounds.

Our Consumers are …..

n
1% NativeAmerican

33% Hispanic
1% Asian

3% African
American

1% are “Others”

Consumers Have Many
Different Lifestyles

Lifestyles

They have many different
beliefs.

Can We Communicate?
Think Language first!
 Do we need an interpreter?
 Communicate respectfully.
 Be sensitive to the consumer and the family.
 Consider your dress, tone of voice, eye contact,
location, seating arrangement, privacy, etc.


Is our approach culturally
appropriate?
“What do you call your problem?”
“What name does it have?”
“What do you think caused your problem?”
“Why do you think it started when it did?”
From Arthur Kleinman’s question protocol in“Culture,Illness, and Care:
Clinical Lessons from Anthropologic and Cross Cultural Research”,
Ann.Intern.Med. 1978:Vol.88, pg.251-258

Important Issues to Consider…





Impact of religion.
How are women, men, elders, and children
treated in their culture?
Is there domestic violence?
Ethnic minorities generally underutilize
outpatient services, although African-Americans
are over-represented in inpatient setting.

Diagnosis






Minorities with Bipolar Disorder are often
diagnosed with schizophrenia. (Mukherjee,et al)
African Americans are over diagnosed with
schizophrenia and under diagnosed with mood
disorders. (Bell )
A mental health consumer’s addictions may not
be treated.
The elderly may not be assessed for substance
abuse or alcoholism.

Diagnosis
A person with a primary addiction problem
might not be treated for a co-occurring mental
illness.
 Learning disabilities may not be identified in
individuals with mental illness or substance
abuse.
 A person with mental retardation may not be
treated for mental illness or substance abuse.


Diagnosis
Post Traumatic Stress Disorder is often
undiagnosed in people suffering from
Domestic Abuse or other trauma.
 Children who are witnessing or are
victims of domestic abuse or another
trauma, may be misdiagnosed with
Attention Deficit Hyperactivity Disorder.


Medication Differences





Asians and Hispanics need lower doses of antipsychotics.
African Americans use the same doses of antipsychotics, but lower doses of lithium.
The elderly need lower dosages of medications.
Thus, metabolism of drugs varies with age and
ethnicity and is critical in prescribing
medications.

From “Making Room for Culture in Psychiatry” by Lin, et al.

Pain Tolerance
Men and women tolerate pain differently.
 Cultures tolerate pain differently.
 People with addictions develop a
hypersensitivity to pain.
 In certain cultures, self-inflicted pain is a
part of a religious experience.


Religion





Religious beliefs shape how the world is viewed.
Is illness a punishment? The devil’s work? An
evil spell? Bad karma?
For Hispanics, the curandero is a trusted healer.
For Lakota Sioux, the ritual Vision Quest,
praying and fasting at a holy site is life
changing.

Remember there are as many
differences
Between individuals in the same
culture as there are between
individuals in different cultures!

Two African American
families, one lesbian
and the other, multi-racial.

German Consumers
Suggestions from our Gillespie County MH staff

What generation German?
 Would they feel more comfortable
speaking in German?


A consumer reacting to internal stimuli.

German Consumers
Suggestions from our Gillespie MHC staff in Fredericksburg

They may be resistant to seeking
mental services.
They may be reluctant to take medication.
They may “keep things within the family.”
They are concerned about the stigma.

German Consumers
They may feel it’s a character flaw or a
disgrace.
 They are very concerned about
confidentiality.
 Drinking alcohol is an accepted part of
their culture.
 Teen drinking may be acceptable in their
family.


Hispanic Consumers
from the U.S. Census, 1/23/03 Houston Chronicle

Hispanics are the largest minority group in
the U.S. with 37 million people.
 Texas is approximately 32 percent
Hispanic
 11.5 % African American,
 3.3% Other
 53.1% Anglo


Treatment Issues for Hispanic
Consumers
Do we need an interpreter?
 Is the person Tejano or from Mexico?
What generation Hispanic?
Is the person using a curandero?

Treatment issues for Hispanic
Consumers
Hallucinations are natural in their
religion.
 Hearing the voice of a loved one or having
hallucinations might be an expectations
when celebrating the Day of the Dead.
 Hispanic families are patriarchal.


Hispanic Consumers and
The Day of the Dead
A man is dressed in a skeleton
costume to portray death
in a celebration of
Dia de los Muertos,
The Day of the Dead.
People visit the graves of their
dead relatives to honor them.

Native Americans

Treatment Issues for Native
American Consumers
 Impact of racism,unemployment,and poverty.
 Coping with reservation life and
assimilation in mainstream culture.
 Consider the obesity, diabetes,
hypertension, and alcoholism in adults
and fetal alcohol syndrome in children.
 High use of native healers in the Southwest.

African Americans

African Americans
from the Houston Chronicle, 1/23/03

There are 36.2 million Americans who
identify themselves as “black only.”
 37.7 million identify themselves as “black
and at least one other race.”
 11.5% of Texans are African Americans.


Treatment Issues for African
American
Assess for co-occurring substance use
disorders and alcoholism.
 Address complications of obesity,
hypertension, diabetes,congestive heart
failure, asthma, and cancer.
 Sickle cell anemia is another illness
specific to African Americans.


Treatment Issues for African
Americans
Matriarchy; Mom or grandmother are the
dominant family figures.
 Lack of male role models and intact
families.
 Extended family or the Church may be
supports.


Treatment Issues for African
Americans


There is discrimination within their own
group based on skin color, hair texture,
class, values, etc.

Treatment Issues for Asians

Asians rarely seek help until its very severe.
Asians have extremely low admissions to state hospitals.
Mental illness is considered shameful. It’s hidden.
Is an interpreter needed?

Treatment Issues for Asians
Focus on physical symptoms.
 Asians are sensitive to medication.
 Give ½ the standard dose.
 Asians may use traditional healers and
herbal medicine.
 Asians may “flush” when drinking
alcohol.


Asian Consumers

Acupuncture has been used to treat
pain, schizophrenia, depression, and addictions.

Treatment Issues for Asians
Asian Cultures are patriarchal.
 The males in the family have the authority.
 Asians are more formal and inhibited in
their social behavior.


Older Adults

Treatment Issues for Older
Adults
Are they aware they need help?

Treatment Issues for Older
Adults
Is their mental illness caused by medicine?
 Do their medical problems cause or
complicate their mental illness?
 Is there Elder Abuse?


Gay Men and Lesbian Women
May struggle with homophobia and“being in the
closet” at work and with their families.
Gay people may want marriage, children, partner
benefits, etc., but may endure legal barriers.

Gay and Lesbian Women
Gay people often have specific health
issues related to their sexual practices.
 HIV, AIDS and STD’s are still concerns
with Gay men.
 People may be grieving the death of a
partner or friends who’ve died from AIDS,
or coping with living with AIDS or being
HIV+ themselves.


Treatment Issues for Gay and
Lesbians
Explore childhood abuse issues and
Domestic Violence..
 Assess for substance use and alcoholism.
 Sex enhancing drug use may be common
among some gay men.


Physically Challenged
Can they get to treatment?
Deal with their frustration and depression
Re: their disability.
 Do they need vocational assistance?

Mentally Challenged

Treatment Issues of Mentally
Challenged
They need to have meaningful activity
and purpose in their lives.
 They need to feel acknowledged and
appreciated.
 They need safety, structure, and security.
 Lack of continuity can cause crisis!
 They may need vocational assistance.


Winona Ryder

December 12, 2001,
Winona Ryder shoplifted
$5,560.40 designer items
from Saks Fifth Avenue in
Beverley Hills.

Twice an Academy
Award Nominated
actress

She had the following 8 drugs in
her possession:
Liquid demerol
 Liquid Diazepam
 Vicodin
 Percodan
 Valium
 Morphine sulfate
 Endocet (containing Oxycodone)


Patterns of Drug Use are highly
Regional.
 Drugs,

routes of administration, street
names, patterns of use, and drug
combinations may differ greatly, not
only between individuals from
different cultures, but different parts
of the country or even different parts
of the city.

Drugs of Choice
Native Americans-alcohol
 Asians-gambling, work
 Gay Men-stimulants, amyl nitrate, ecstasy
 “Rich”-prescription drugs, Internet porn
 M.D.’s –Vicodin


Drugs of Choice
Young adults-marijuana, cigarettes
 Geriatrics-alcohol, pills
 Sex Workers-crack cocaine, IV speedballs
 Screen mentally retarded for abuse too!


How Do We Best Serve Our
Consumers?




Examine own stereotypes.
Build trust.
Use People First language!

How do we best serve our
consumers?
Pronounce the person’s name correctly.
 Get an interpreter, if necessary.
 Educate yourself from the consumer, his
family, co-workers, etc.
 Remember differences do matter!



Slide 43

Cultural Competence
Integrating Differences
into Community Services

Objectives
Understand Stigma.
 Understand Culture Competency.
 Learn Culturally competent care for
people with Mental Health, Mental
Retardation and Addictions.


We live in an world
which often separates us.
Racism
 Sexism
 Ageism
 Feminism
 Classism
 Atheism


“Different” people are
“Stigmatized”

Mentally retarded inmates in a sanitorium in Germany

Stigma
Definitions from the U. of Chicago PSR Training Manual

“Stigmas are negative attitudes about a
group that lead to depriving them of
some fair opportunities.”

Stigma is related to…..
Stereotypes
Prejudice
Discrimination

Stereotypes
from The Asian Health Coalition of Illinois

Stereotypes are exaggerated beliefs
or fixed ideas about a person or
group which is held by people and
sustained by selective perception and
selective forgetting.

Prejudice
from The Asian Health Coalition of Illinois

Prejudice is a preconceived idea or
negative attitude formed before the
facts are known and sustained over
generalizations. A bias without
reason, resisting all evidence…

Discrimination
from The Asian Health Coalition of Illinois

Discrimination refers to treatment in
favor or against a person based on
the group to which that person
belongs and not on merit.

Stigmatized People…..
Experience being stereotyped and
are often the object of
discrimination and prejudice.

People are often stigmatized by:













Mental Illness
Mental Retardation
Physical Disability (including blindness, deafness)
Alcoholism /and or Drug Addiction
HIV or AIDS, Cancer or other terminal illnesses
Criminal behavior
Poverty
Alternative Lifestyles/sexual orientation
Wheelchair bound
Gender
Obesity

All our Consumers belong to
stigmatized groups!

Stigmatized People
Consumers and their families
can’t navigate the bureaucracy
even if resources are there.
It’s too frustrating!

Use People First Language
“I am more than my
illness….Don’t call me
“the schizophrenic,
“the addict” or
“the retard.”

As human beings, we have many
similarities…..
But, who we really are, is often
derived from our original family of origin
and our current lifestyle.

The Bottom Line:
People are different, even within
their own culture!
These differences matter when
planning and providing services.

National Mental Health
Association
“For Mental Health consumers, both
access to the services and the effectiveness
of the care they receive are greatly affected
by the degree to which the delivery system
is“culturally competent.”

Some important definitions
Related to Cultural Competency

Culture

from King,et. al

The Office of Special Programs, U.S. Dept. of Education

“The integrated patterns of human
behavior that includes thoughts,
communications, actions, customs,
beliefs,values, and institutions of
racial, ethnic, religious, or social
groups.”

Cultural Sensitivity
An awareness and respect of a
person’s cultural beliefs and
values.
Culhane-Pera, et .al

Cultural Competency
 Skills

(that translate into)
 Behaviors, Practices, Attitudes, and
 Policies
That enable an individual, agency, or
system to effectively serve culturally
diverse communities.
from The Asian Health Coalition of Illinois

Here at Hill Country MHDDC
Consumers are very diverse in their
language and culture.

61% of our Consumers are
Caucasian Americans
Many have German
backgrounds.

Our Consumers are …..

n
1% NativeAmerican

33% Hispanic
1% Asian

3% African
American

1% are “Others”

Consumers Have Many
Different Lifestyles

Lifestyles

They have many different
beliefs.

Can We Communicate?
Think Language first!
 Do we need an interpreter?
 Communicate respectfully.
 Be sensitive to the consumer and the family.
 Consider your dress, tone of voice, eye contact,
location, seating arrangement, privacy, etc.


Is our approach culturally
appropriate?
“What do you call your problem?”
“What name does it have?”
“What do you think caused your problem?”
“Why do you think it started when it did?”
From Arthur Kleinman’s question protocol in“Culture,Illness, and Care:
Clinical Lessons from Anthropologic and Cross Cultural Research”,
Ann.Intern.Med. 1978:Vol.88, pg.251-258

Important Issues to Consider…





Impact of religion.
How are women, men, elders, and children
treated in their culture?
Is there domestic violence?
Ethnic minorities generally underutilize
outpatient services, although African-Americans
are over-represented in inpatient setting.

Diagnosis






Minorities with Bipolar Disorder are often
diagnosed with schizophrenia. (Mukherjee,et al)
African Americans are over diagnosed with
schizophrenia and under diagnosed with mood
disorders. (Bell )
A mental health consumer’s addictions may not
be treated.
The elderly may not be assessed for substance
abuse or alcoholism.

Diagnosis
A person with a primary addiction problem
might not be treated for a co-occurring mental
illness.
 Learning disabilities may not be identified in
individuals with mental illness or substance
abuse.
 A person with mental retardation may not be
treated for mental illness or substance abuse.


Diagnosis
Post Traumatic Stress Disorder is often
undiagnosed in people suffering from
Domestic Abuse or other trauma.
 Children who are witnessing or are
victims of domestic abuse or another
trauma, may be misdiagnosed with
Attention Deficit Hyperactivity Disorder.


Medication Differences





Asians and Hispanics need lower doses of antipsychotics.
African Americans use the same doses of antipsychotics, but lower doses of lithium.
The elderly need lower dosages of medications.
Thus, metabolism of drugs varies with age and
ethnicity and is critical in prescribing
medications.

From “Making Room for Culture in Psychiatry” by Lin, et al.

Pain Tolerance
Men and women tolerate pain differently.
 Cultures tolerate pain differently.
 People with addictions develop a
hypersensitivity to pain.
 In certain cultures, self-inflicted pain is a
part of a religious experience.


Religion





Religious beliefs shape how the world is viewed.
Is illness a punishment? The devil’s work? An
evil spell? Bad karma?
For Hispanics, the curandero is a trusted healer.
For Lakota Sioux, the ritual Vision Quest,
praying and fasting at a holy site is life
changing.

Remember there are as many
differences
Between individuals in the same
culture as there are between
individuals in different cultures!

Two African American
families, one lesbian
and the other, multi-racial.

German Consumers
Suggestions from our Gillespie County MH staff

What generation German?
 Would they feel more comfortable
speaking in German?


A consumer reacting to internal stimuli.

German Consumers
Suggestions from our Gillespie MHC staff in Fredericksburg

They may be resistant to seeking
mental services.
They may be reluctant to take medication.
They may “keep things within the family.”
They are concerned about the stigma.

German Consumers
They may feel it’s a character flaw or a
disgrace.
 They are very concerned about
confidentiality.
 Drinking alcohol is an accepted part of
their culture.
 Teen drinking may be acceptable in their
family.


Hispanic Consumers
from the U.S. Census, 1/23/03 Houston Chronicle

Hispanics are the largest minority group in
the U.S. with 37 million people.
 Texas is approximately 32 percent
Hispanic
 11.5 % African American,
 3.3% Other
 53.1% Anglo


Treatment Issues for Hispanic
Consumers
Do we need an interpreter?
 Is the person Tejano or from Mexico?
What generation Hispanic?
Is the person using a curandero?

Treatment issues for Hispanic
Consumers
Hallucinations are natural in their
religion.
 Hearing the voice of a loved one or having
hallucinations might be an expectations
when celebrating the Day of the Dead.
 Hispanic families are patriarchal.


Hispanic Consumers and
The Day of the Dead
A man is dressed in a skeleton
costume to portray death
in a celebration of
Dia de los Muertos,
The Day of the Dead.
People visit the graves of their
dead relatives to honor them.

Native Americans

Treatment Issues for Native
American Consumers
 Impact of racism,unemployment,and poverty.
 Coping with reservation life and
assimilation in mainstream culture.
 Consider the obesity, diabetes,
hypertension, and alcoholism in adults
and fetal alcohol syndrome in children.
 High use of native healers in the Southwest.

African Americans

African Americans
from the Houston Chronicle, 1/23/03

There are 36.2 million Americans who
identify themselves as “black only.”
 37.7 million identify themselves as “black
and at least one other race.”
 11.5% of Texans are African Americans.


Treatment Issues for African
American
Assess for co-occurring substance use
disorders and alcoholism.
 Address complications of obesity,
hypertension, diabetes,congestive heart
failure, asthma, and cancer.
 Sickle cell anemia is another illness
specific to African Americans.


Treatment Issues for African
Americans
Matriarchy; Mom or grandmother are the
dominant family figures.
 Lack of male role models and intact
families.
 Extended family or the Church may be
supports.


Treatment Issues for African
Americans


There is discrimination within their own
group based on skin color, hair texture,
class, values, etc.

Treatment Issues for Asians

Asians rarely seek help until its very severe.
Asians have extremely low admissions to state hospitals.
Mental illness is considered shameful. It’s hidden.
Is an interpreter needed?

Treatment Issues for Asians
Focus on physical symptoms.
 Asians are sensitive to medication.
 Give ½ the standard dose.
 Asians may use traditional healers and
herbal medicine.
 Asians may “flush” when drinking
alcohol.


Asian Consumers

Acupuncture has been used to treat
pain, schizophrenia, depression, and addictions.

Treatment Issues for Asians
Asian Cultures are patriarchal.
 The males in the family have the authority.
 Asians are more formal and inhibited in
their social behavior.


Older Adults

Treatment Issues for Older
Adults
Are they aware they need help?

Treatment Issues for Older
Adults
Is their mental illness caused by medicine?
 Do their medical problems cause or
complicate their mental illness?
 Is there Elder Abuse?


Gay Men and Lesbian Women
May struggle with homophobia and“being in the
closet” at work and with their families.
Gay people may want marriage, children, partner
benefits, etc., but may endure legal barriers.

Gay and Lesbian Women
Gay people often have specific health
issues related to their sexual practices.
 HIV, AIDS and STD’s are still concerns
with Gay men.
 People may be grieving the death of a
partner or friends who’ve died from AIDS,
or coping with living with AIDS or being
HIV+ themselves.


Treatment Issues for Gay and
Lesbians
Explore childhood abuse issues and
Domestic Violence..
 Assess for substance use and alcoholism.
 Sex enhancing drug use may be common
among some gay men.


Physically Challenged
Can they get to treatment?
Deal with their frustration and depression
Re: their disability.
 Do they need vocational assistance?

Mentally Challenged

Treatment Issues of Mentally
Challenged
They need to have meaningful activity
and purpose in their lives.
 They need to feel acknowledged and
appreciated.
 They need safety, structure, and security.
 Lack of continuity can cause crisis!
 They may need vocational assistance.


Winona Ryder

December 12, 2001,
Winona Ryder shoplifted
$5,560.40 designer items
from Saks Fifth Avenue in
Beverley Hills.

Twice an Academy
Award Nominated
actress

She had the following 8 drugs in
her possession:
Liquid demerol
 Liquid Diazepam
 Vicodin
 Percodan
 Valium
 Morphine sulfate
 Endocet (containing Oxycodone)


Patterns of Drug Use are highly
Regional.
 Drugs,

routes of administration, street
names, patterns of use, and drug
combinations may differ greatly, not
only between individuals from
different cultures, but different parts
of the country or even different parts
of the city.

Drugs of Choice
Native Americans-alcohol
 Asians-gambling, work
 Gay Men-stimulants, amyl nitrate, ecstasy
 “Rich”-prescription drugs, Internet porn
 M.D.’s –Vicodin


Drugs of Choice
Young adults-marijuana, cigarettes
 Geriatrics-alcohol, pills
 Sex Workers-crack cocaine, IV speedballs
 Screen mentally retarded for abuse too!


How Do We Best Serve Our
Consumers?




Examine own stereotypes.
Build trust.
Use People First language!

How do we best serve our
consumers?
Pronounce the person’s name correctly.
 Get an interpreter, if necessary.
 Educate yourself from the consumer, his
family, co-workers, etc.
 Remember differences do matter!



Slide 44

Cultural Competence
Integrating Differences
into Community Services

Objectives
Understand Stigma.
 Understand Culture Competency.
 Learn Culturally competent care for
people with Mental Health, Mental
Retardation and Addictions.


We live in an world
which often separates us.
Racism
 Sexism
 Ageism
 Feminism
 Classism
 Atheism


“Different” people are
“Stigmatized”

Mentally retarded inmates in a sanitorium in Germany

Stigma
Definitions from the U. of Chicago PSR Training Manual

“Stigmas are negative attitudes about a
group that lead to depriving them of
some fair opportunities.”

Stigma is related to…..
Stereotypes
Prejudice
Discrimination

Stereotypes
from The Asian Health Coalition of Illinois

Stereotypes are exaggerated beliefs
or fixed ideas about a person or
group which is held by people and
sustained by selective perception and
selective forgetting.

Prejudice
from The Asian Health Coalition of Illinois

Prejudice is a preconceived idea or
negative attitude formed before the
facts are known and sustained over
generalizations. A bias without
reason, resisting all evidence…

Discrimination
from The Asian Health Coalition of Illinois

Discrimination refers to treatment in
favor or against a person based on
the group to which that person
belongs and not on merit.

Stigmatized People…..
Experience being stereotyped and
are often the object of
discrimination and prejudice.

People are often stigmatized by:













Mental Illness
Mental Retardation
Physical Disability (including blindness, deafness)
Alcoholism /and or Drug Addiction
HIV or AIDS, Cancer or other terminal illnesses
Criminal behavior
Poverty
Alternative Lifestyles/sexual orientation
Wheelchair bound
Gender
Obesity

All our Consumers belong to
stigmatized groups!

Stigmatized People
Consumers and their families
can’t navigate the bureaucracy
even if resources are there.
It’s too frustrating!

Use People First Language
“I am more than my
illness….Don’t call me
“the schizophrenic,
“the addict” or
“the retard.”

As human beings, we have many
similarities…..
But, who we really are, is often
derived from our original family of origin
and our current lifestyle.

The Bottom Line:
People are different, even within
their own culture!
These differences matter when
planning and providing services.

National Mental Health
Association
“For Mental Health consumers, both
access to the services and the effectiveness
of the care they receive are greatly affected
by the degree to which the delivery system
is“culturally competent.”

Some important definitions
Related to Cultural Competency

Culture

from King,et. al

The Office of Special Programs, U.S. Dept. of Education

“The integrated patterns of human
behavior that includes thoughts,
communications, actions, customs,
beliefs,values, and institutions of
racial, ethnic, religious, or social
groups.”

Cultural Sensitivity
An awareness and respect of a
person’s cultural beliefs and
values.
Culhane-Pera, et .al

Cultural Competency
 Skills

(that translate into)
 Behaviors, Practices, Attitudes, and
 Policies
That enable an individual, agency, or
system to effectively serve culturally
diverse communities.
from The Asian Health Coalition of Illinois

Here at Hill Country MHDDC
Consumers are very diverse in their
language and culture.

61% of our Consumers are
Caucasian Americans
Many have German
backgrounds.

Our Consumers are …..

n
1% NativeAmerican

33% Hispanic
1% Asian

3% African
American

1% are “Others”

Consumers Have Many
Different Lifestyles

Lifestyles

They have many different
beliefs.

Can We Communicate?
Think Language first!
 Do we need an interpreter?
 Communicate respectfully.
 Be sensitive to the consumer and the family.
 Consider your dress, tone of voice, eye contact,
location, seating arrangement, privacy, etc.


Is our approach culturally
appropriate?
“What do you call your problem?”
“What name does it have?”
“What do you think caused your problem?”
“Why do you think it started when it did?”
From Arthur Kleinman’s question protocol in“Culture,Illness, and Care:
Clinical Lessons from Anthropologic and Cross Cultural Research”,
Ann.Intern.Med. 1978:Vol.88, pg.251-258

Important Issues to Consider…





Impact of religion.
How are women, men, elders, and children
treated in their culture?
Is there domestic violence?
Ethnic minorities generally underutilize
outpatient services, although African-Americans
are over-represented in inpatient setting.

Diagnosis






Minorities with Bipolar Disorder are often
diagnosed with schizophrenia. (Mukherjee,et al)
African Americans are over diagnosed with
schizophrenia and under diagnosed with mood
disorders. (Bell )
A mental health consumer’s addictions may not
be treated.
The elderly may not be assessed for substance
abuse or alcoholism.

Diagnosis
A person with a primary addiction problem
might not be treated for a co-occurring mental
illness.
 Learning disabilities may not be identified in
individuals with mental illness or substance
abuse.
 A person with mental retardation may not be
treated for mental illness or substance abuse.


Diagnosis
Post Traumatic Stress Disorder is often
undiagnosed in people suffering from
Domestic Abuse or other trauma.
 Children who are witnessing or are
victims of domestic abuse or another
trauma, may be misdiagnosed with
Attention Deficit Hyperactivity Disorder.


Medication Differences





Asians and Hispanics need lower doses of antipsychotics.
African Americans use the same doses of antipsychotics, but lower doses of lithium.
The elderly need lower dosages of medications.
Thus, metabolism of drugs varies with age and
ethnicity and is critical in prescribing
medications.

From “Making Room for Culture in Psychiatry” by Lin, et al.

Pain Tolerance
Men and women tolerate pain differently.
 Cultures tolerate pain differently.
 People with addictions develop a
hypersensitivity to pain.
 In certain cultures, self-inflicted pain is a
part of a religious experience.


Religion





Religious beliefs shape how the world is viewed.
Is illness a punishment? The devil’s work? An
evil spell? Bad karma?
For Hispanics, the curandero is a trusted healer.
For Lakota Sioux, the ritual Vision Quest,
praying and fasting at a holy site is life
changing.

Remember there are as many
differences
Between individuals in the same
culture as there are between
individuals in different cultures!

Two African American
families, one lesbian
and the other, multi-racial.

German Consumers
Suggestions from our Gillespie County MH staff

What generation German?
 Would they feel more comfortable
speaking in German?


A consumer reacting to internal stimuli.

German Consumers
Suggestions from our Gillespie MHC staff in Fredericksburg

They may be resistant to seeking
mental services.
They may be reluctant to take medication.
They may “keep things within the family.”
They are concerned about the stigma.

German Consumers
They may feel it’s a character flaw or a
disgrace.
 They are very concerned about
confidentiality.
 Drinking alcohol is an accepted part of
their culture.
 Teen drinking may be acceptable in their
family.


Hispanic Consumers
from the U.S. Census, 1/23/03 Houston Chronicle

Hispanics are the largest minority group in
the U.S. with 37 million people.
 Texas is approximately 32 percent
Hispanic
 11.5 % African American,
 3.3% Other
 53.1% Anglo


Treatment Issues for Hispanic
Consumers
Do we need an interpreter?
 Is the person Tejano or from Mexico?
What generation Hispanic?
Is the person using a curandero?

Treatment issues for Hispanic
Consumers
Hallucinations are natural in their
religion.
 Hearing the voice of a loved one or having
hallucinations might be an expectations
when celebrating the Day of the Dead.
 Hispanic families are patriarchal.


Hispanic Consumers and
The Day of the Dead
A man is dressed in a skeleton
costume to portray death
in a celebration of
Dia de los Muertos,
The Day of the Dead.
People visit the graves of their
dead relatives to honor them.

Native Americans

Treatment Issues for Native
American Consumers
 Impact of racism,unemployment,and poverty.
 Coping with reservation life and
assimilation in mainstream culture.
 Consider the obesity, diabetes,
hypertension, and alcoholism in adults
and fetal alcohol syndrome in children.
 High use of native healers in the Southwest.

African Americans

African Americans
from the Houston Chronicle, 1/23/03

There are 36.2 million Americans who
identify themselves as “black only.”
 37.7 million identify themselves as “black
and at least one other race.”
 11.5% of Texans are African Americans.


Treatment Issues for African
American
Assess for co-occurring substance use
disorders and alcoholism.
 Address complications of obesity,
hypertension, diabetes,congestive heart
failure, asthma, and cancer.
 Sickle cell anemia is another illness
specific to African Americans.


Treatment Issues for African
Americans
Matriarchy; Mom or grandmother are the
dominant family figures.
 Lack of male role models and intact
families.
 Extended family or the Church may be
supports.


Treatment Issues for African
Americans


There is discrimination within their own
group based on skin color, hair texture,
class, values, etc.

Treatment Issues for Asians

Asians rarely seek help until its very severe.
Asians have extremely low admissions to state hospitals.
Mental illness is considered shameful. It’s hidden.
Is an interpreter needed?

Treatment Issues for Asians
Focus on physical symptoms.
 Asians are sensitive to medication.
 Give ½ the standard dose.
 Asians may use traditional healers and
herbal medicine.
 Asians may “flush” when drinking
alcohol.


Asian Consumers

Acupuncture has been used to treat
pain, schizophrenia, depression, and addictions.

Treatment Issues for Asians
Asian Cultures are patriarchal.
 The males in the family have the authority.
 Asians are more formal and inhibited in
their social behavior.


Older Adults

Treatment Issues for Older
Adults
Are they aware they need help?

Treatment Issues for Older
Adults
Is their mental illness caused by medicine?
 Do their medical problems cause or
complicate their mental illness?
 Is there Elder Abuse?


Gay Men and Lesbian Women
May struggle with homophobia and“being in the
closet” at work and with their families.
Gay people may want marriage, children, partner
benefits, etc., but may endure legal barriers.

Gay and Lesbian Women
Gay people often have specific health
issues related to their sexual practices.
 HIV, AIDS and STD’s are still concerns
with Gay men.
 People may be grieving the death of a
partner or friends who’ve died from AIDS,
or coping with living with AIDS or being
HIV+ themselves.


Treatment Issues for Gay and
Lesbians
Explore childhood abuse issues and
Domestic Violence..
 Assess for substance use and alcoholism.
 Sex enhancing drug use may be common
among some gay men.


Physically Challenged
Can they get to treatment?
Deal with their frustration and depression
Re: their disability.
 Do they need vocational assistance?

Mentally Challenged

Treatment Issues of Mentally
Challenged
They need to have meaningful activity
and purpose in their lives.
 They need to feel acknowledged and
appreciated.
 They need safety, structure, and security.
 Lack of continuity can cause crisis!
 They may need vocational assistance.


Winona Ryder

December 12, 2001,
Winona Ryder shoplifted
$5,560.40 designer items
from Saks Fifth Avenue in
Beverley Hills.

Twice an Academy
Award Nominated
actress

She had the following 8 drugs in
her possession:
Liquid demerol
 Liquid Diazepam
 Vicodin
 Percodan
 Valium
 Morphine sulfate
 Endocet (containing Oxycodone)


Patterns of Drug Use are highly
Regional.
 Drugs,

routes of administration, street
names, patterns of use, and drug
combinations may differ greatly, not
only between individuals from
different cultures, but different parts
of the country or even different parts
of the city.

Drugs of Choice
Native Americans-alcohol
 Asians-gambling, work
 Gay Men-stimulants, amyl nitrate, ecstasy
 “Rich”-prescription drugs, Internet porn
 M.D.’s –Vicodin


Drugs of Choice
Young adults-marijuana, cigarettes
 Geriatrics-alcohol, pills
 Sex Workers-crack cocaine, IV speedballs
 Screen mentally retarded for abuse too!


How Do We Best Serve Our
Consumers?




Examine own stereotypes.
Build trust.
Use People First language!

How do we best serve our
consumers?
Pronounce the person’s name correctly.
 Get an interpreter, if necessary.
 Educate yourself from the consumer, his
family, co-workers, etc.
 Remember differences do matter!



Slide 45

Cultural Competence
Integrating Differences
into Community Services

Objectives
Understand Stigma.
 Understand Culture Competency.
 Learn Culturally competent care for
people with Mental Health, Mental
Retardation and Addictions.


We live in an world
which often separates us.
Racism
 Sexism
 Ageism
 Feminism
 Classism
 Atheism


“Different” people are
“Stigmatized”

Mentally retarded inmates in a sanitorium in Germany

Stigma
Definitions from the U. of Chicago PSR Training Manual

“Stigmas are negative attitudes about a
group that lead to depriving them of
some fair opportunities.”

Stigma is related to…..
Stereotypes
Prejudice
Discrimination

Stereotypes
from The Asian Health Coalition of Illinois

Stereotypes are exaggerated beliefs
or fixed ideas about a person or
group which is held by people and
sustained by selective perception and
selective forgetting.

Prejudice
from The Asian Health Coalition of Illinois

Prejudice is a preconceived idea or
negative attitude formed before the
facts are known and sustained over
generalizations. A bias without
reason, resisting all evidence…

Discrimination
from The Asian Health Coalition of Illinois

Discrimination refers to treatment in
favor or against a person based on
the group to which that person
belongs and not on merit.

Stigmatized People…..
Experience being stereotyped and
are often the object of
discrimination and prejudice.

People are often stigmatized by:













Mental Illness
Mental Retardation
Physical Disability (including blindness, deafness)
Alcoholism /and or Drug Addiction
HIV or AIDS, Cancer or other terminal illnesses
Criminal behavior
Poverty
Alternative Lifestyles/sexual orientation
Wheelchair bound
Gender
Obesity

All our Consumers belong to
stigmatized groups!

Stigmatized People
Consumers and their families
can’t navigate the bureaucracy
even if resources are there.
It’s too frustrating!

Use People First Language
“I am more than my
illness….Don’t call me
“the schizophrenic,
“the addict” or
“the retard.”

As human beings, we have many
similarities…..
But, who we really are, is often
derived from our original family of origin
and our current lifestyle.

The Bottom Line:
People are different, even within
their own culture!
These differences matter when
planning and providing services.

National Mental Health
Association
“For Mental Health consumers, both
access to the services and the effectiveness
of the care they receive are greatly affected
by the degree to which the delivery system
is“culturally competent.”

Some important definitions
Related to Cultural Competency

Culture

from King,et. al

The Office of Special Programs, U.S. Dept. of Education

“The integrated patterns of human
behavior that includes thoughts,
communications, actions, customs,
beliefs,values, and institutions of
racial, ethnic, religious, or social
groups.”

Cultural Sensitivity
An awareness and respect of a
person’s cultural beliefs and
values.
Culhane-Pera, et .al

Cultural Competency
 Skills

(that translate into)
 Behaviors, Practices, Attitudes, and
 Policies
That enable an individual, agency, or
system to effectively serve culturally
diverse communities.
from The Asian Health Coalition of Illinois

Here at Hill Country MHDDC
Consumers are very diverse in their
language and culture.

61% of our Consumers are
Caucasian Americans
Many have German
backgrounds.

Our Consumers are …..

n
1% NativeAmerican

33% Hispanic
1% Asian

3% African
American

1% are “Others”

Consumers Have Many
Different Lifestyles

Lifestyles

They have many different
beliefs.

Can We Communicate?
Think Language first!
 Do we need an interpreter?
 Communicate respectfully.
 Be sensitive to the consumer and the family.
 Consider your dress, tone of voice, eye contact,
location, seating arrangement, privacy, etc.


Is our approach culturally
appropriate?
“What do you call your problem?”
“What name does it have?”
“What do you think caused your problem?”
“Why do you think it started when it did?”
From Arthur Kleinman’s question protocol in“Culture,Illness, and Care:
Clinical Lessons from Anthropologic and Cross Cultural Research”,
Ann.Intern.Med. 1978:Vol.88, pg.251-258

Important Issues to Consider…





Impact of religion.
How are women, men, elders, and children
treated in their culture?
Is there domestic violence?
Ethnic minorities generally underutilize
outpatient services, although African-Americans
are over-represented in inpatient setting.

Diagnosis






Minorities with Bipolar Disorder are often
diagnosed with schizophrenia. (Mukherjee,et al)
African Americans are over diagnosed with
schizophrenia and under diagnosed with mood
disorders. (Bell )
A mental health consumer’s addictions may not
be treated.
The elderly may not be assessed for substance
abuse or alcoholism.

Diagnosis
A person with a primary addiction problem
might not be treated for a co-occurring mental
illness.
 Learning disabilities may not be identified in
individuals with mental illness or substance
abuse.
 A person with mental retardation may not be
treated for mental illness or substance abuse.


Diagnosis
Post Traumatic Stress Disorder is often
undiagnosed in people suffering from
Domestic Abuse or other trauma.
 Children who are witnessing or are
victims of domestic abuse or another
trauma, may be misdiagnosed with
Attention Deficit Hyperactivity Disorder.


Medication Differences





Asians and Hispanics need lower doses of antipsychotics.
African Americans use the same doses of antipsychotics, but lower doses of lithium.
The elderly need lower dosages of medications.
Thus, metabolism of drugs varies with age and
ethnicity and is critical in prescribing
medications.

From “Making Room for Culture in Psychiatry” by Lin, et al.

Pain Tolerance
Men and women tolerate pain differently.
 Cultures tolerate pain differently.
 People with addictions develop a
hypersensitivity to pain.
 In certain cultures, self-inflicted pain is a
part of a religious experience.


Religion





Religious beliefs shape how the world is viewed.
Is illness a punishment? The devil’s work? An
evil spell? Bad karma?
For Hispanics, the curandero is a trusted healer.
For Lakota Sioux, the ritual Vision Quest,
praying and fasting at a holy site is life
changing.

Remember there are as many
differences
Between individuals in the same
culture as there are between
individuals in different cultures!

Two African American
families, one lesbian
and the other, multi-racial.

German Consumers
Suggestions from our Gillespie County MH staff

What generation German?
 Would they feel more comfortable
speaking in German?


A consumer reacting to internal stimuli.

German Consumers
Suggestions from our Gillespie MHC staff in Fredericksburg

They may be resistant to seeking
mental services.
They may be reluctant to take medication.
They may “keep things within the family.”
They are concerned about the stigma.

German Consumers
They may feel it’s a character flaw or a
disgrace.
 They are very concerned about
confidentiality.
 Drinking alcohol is an accepted part of
their culture.
 Teen drinking may be acceptable in their
family.


Hispanic Consumers
from the U.S. Census, 1/23/03 Houston Chronicle

Hispanics are the largest minority group in
the U.S. with 37 million people.
 Texas is approximately 32 percent
Hispanic
 11.5 % African American,
 3.3% Other
 53.1% Anglo


Treatment Issues for Hispanic
Consumers
Do we need an interpreter?
 Is the person Tejano or from Mexico?
What generation Hispanic?
Is the person using a curandero?

Treatment issues for Hispanic
Consumers
Hallucinations are natural in their
religion.
 Hearing the voice of a loved one or having
hallucinations might be an expectations
when celebrating the Day of the Dead.
 Hispanic families are patriarchal.


Hispanic Consumers and
The Day of the Dead
A man is dressed in a skeleton
costume to portray death
in a celebration of
Dia de los Muertos,
The Day of the Dead.
People visit the graves of their
dead relatives to honor them.

Native Americans

Treatment Issues for Native
American Consumers
 Impact of racism,unemployment,and poverty.
 Coping with reservation life and
assimilation in mainstream culture.
 Consider the obesity, diabetes,
hypertension, and alcoholism in adults
and fetal alcohol syndrome in children.
 High use of native healers in the Southwest.

African Americans

African Americans
from the Houston Chronicle, 1/23/03

There are 36.2 million Americans who
identify themselves as “black only.”
 37.7 million identify themselves as “black
and at least one other race.”
 11.5% of Texans are African Americans.


Treatment Issues for African
American
Assess for co-occurring substance use
disorders and alcoholism.
 Address complications of obesity,
hypertension, diabetes,congestive heart
failure, asthma, and cancer.
 Sickle cell anemia is another illness
specific to African Americans.


Treatment Issues for African
Americans
Matriarchy; Mom or grandmother are the
dominant family figures.
 Lack of male role models and intact
families.
 Extended family or the Church may be
supports.


Treatment Issues for African
Americans


There is discrimination within their own
group based on skin color, hair texture,
class, values, etc.

Treatment Issues for Asians

Asians rarely seek help until its very severe.
Asians have extremely low admissions to state hospitals.
Mental illness is considered shameful. It’s hidden.
Is an interpreter needed?

Treatment Issues for Asians
Focus on physical symptoms.
 Asians are sensitive to medication.
 Give ½ the standard dose.
 Asians may use traditional healers and
herbal medicine.
 Asians may “flush” when drinking
alcohol.


Asian Consumers

Acupuncture has been used to treat
pain, schizophrenia, depression, and addictions.

Treatment Issues for Asians
Asian Cultures are patriarchal.
 The males in the family have the authority.
 Asians are more formal and inhibited in
their social behavior.


Older Adults

Treatment Issues for Older
Adults
Are they aware they need help?

Treatment Issues for Older
Adults
Is their mental illness caused by medicine?
 Do their medical problems cause or
complicate their mental illness?
 Is there Elder Abuse?


Gay Men and Lesbian Women
May struggle with homophobia and“being in the
closet” at work and with their families.
Gay people may want marriage, children, partner
benefits, etc., but may endure legal barriers.

Gay and Lesbian Women
Gay people often have specific health
issues related to their sexual practices.
 HIV, AIDS and STD’s are still concerns
with Gay men.
 People may be grieving the death of a
partner or friends who’ve died from AIDS,
or coping with living with AIDS or being
HIV+ themselves.


Treatment Issues for Gay and
Lesbians
Explore childhood abuse issues and
Domestic Violence..
 Assess for substance use and alcoholism.
 Sex enhancing drug use may be common
among some gay men.


Physically Challenged
Can they get to treatment?
Deal with their frustration and depression
Re: their disability.
 Do they need vocational assistance?

Mentally Challenged

Treatment Issues of Mentally
Challenged
They need to have meaningful activity
and purpose in their lives.
 They need to feel acknowledged and
appreciated.
 They need safety, structure, and security.
 Lack of continuity can cause crisis!
 They may need vocational assistance.


Winona Ryder

December 12, 2001,
Winona Ryder shoplifted
$5,560.40 designer items
from Saks Fifth Avenue in
Beverley Hills.

Twice an Academy
Award Nominated
actress

She had the following 8 drugs in
her possession:
Liquid demerol
 Liquid Diazepam
 Vicodin
 Percodan
 Valium
 Morphine sulfate
 Endocet (containing Oxycodone)


Patterns of Drug Use are highly
Regional.
 Drugs,

routes of administration, street
names, patterns of use, and drug
combinations may differ greatly, not
only between individuals from
different cultures, but different parts
of the country or even different parts
of the city.

Drugs of Choice
Native Americans-alcohol
 Asians-gambling, work
 Gay Men-stimulants, amyl nitrate, ecstasy
 “Rich”-prescription drugs, Internet porn
 M.D.’s –Vicodin


Drugs of Choice
Young adults-marijuana, cigarettes
 Geriatrics-alcohol, pills
 Sex Workers-crack cocaine, IV speedballs
 Screen mentally retarded for abuse too!


How Do We Best Serve Our
Consumers?




Examine own stereotypes.
Build trust.
Use People First language!

How do we best serve our
consumers?
Pronounce the person’s name correctly.
 Get an interpreter, if necessary.
 Educate yourself from the consumer, his
family, co-workers, etc.
 Remember differences do matter!



Slide 46

Cultural Competence
Integrating Differences
into Community Services

Objectives
Understand Stigma.
 Understand Culture Competency.
 Learn Culturally competent care for
people with Mental Health, Mental
Retardation and Addictions.


We live in an world
which often separates us.
Racism
 Sexism
 Ageism
 Feminism
 Classism
 Atheism


“Different” people are
“Stigmatized”

Mentally retarded inmates in a sanitorium in Germany

Stigma
Definitions from the U. of Chicago PSR Training Manual

“Stigmas are negative attitudes about a
group that lead to depriving them of
some fair opportunities.”

Stigma is related to…..
Stereotypes
Prejudice
Discrimination

Stereotypes
from The Asian Health Coalition of Illinois

Stereotypes are exaggerated beliefs
or fixed ideas about a person or
group which is held by people and
sustained by selective perception and
selective forgetting.

Prejudice
from The Asian Health Coalition of Illinois

Prejudice is a preconceived idea or
negative attitude formed before the
facts are known and sustained over
generalizations. A bias without
reason, resisting all evidence…

Discrimination
from The Asian Health Coalition of Illinois

Discrimination refers to treatment in
favor or against a person based on
the group to which that person
belongs and not on merit.

Stigmatized People…..
Experience being stereotyped and
are often the object of
discrimination and prejudice.

People are often stigmatized by:













Mental Illness
Mental Retardation
Physical Disability (including blindness, deafness)
Alcoholism /and or Drug Addiction
HIV or AIDS, Cancer or other terminal illnesses
Criminal behavior
Poverty
Alternative Lifestyles/sexual orientation
Wheelchair bound
Gender
Obesity

All our Consumers belong to
stigmatized groups!

Stigmatized People
Consumers and their families
can’t navigate the bureaucracy
even if resources are there.
It’s too frustrating!

Use People First Language
“I am more than my
illness….Don’t call me
“the schizophrenic,
“the addict” or
“the retard.”

As human beings, we have many
similarities…..
But, who we really are, is often
derived from our original family of origin
and our current lifestyle.

The Bottom Line:
People are different, even within
their own culture!
These differences matter when
planning and providing services.

National Mental Health
Association
“For Mental Health consumers, both
access to the services and the effectiveness
of the care they receive are greatly affected
by the degree to which the delivery system
is“culturally competent.”

Some important definitions
Related to Cultural Competency

Culture

from King,et. al

The Office of Special Programs, U.S. Dept. of Education

“The integrated patterns of human
behavior that includes thoughts,
communications, actions, customs,
beliefs,values, and institutions of
racial, ethnic, religious, or social
groups.”

Cultural Sensitivity
An awareness and respect of a
person’s cultural beliefs and
values.
Culhane-Pera, et .al

Cultural Competency
 Skills

(that translate into)
 Behaviors, Practices, Attitudes, and
 Policies
That enable an individual, agency, or
system to effectively serve culturally
diverse communities.
from The Asian Health Coalition of Illinois

Here at Hill Country MHDDC
Consumers are very diverse in their
language and culture.

61% of our Consumers are
Caucasian Americans
Many have German
backgrounds.

Our Consumers are …..

n
1% NativeAmerican

33% Hispanic
1% Asian

3% African
American

1% are “Others”

Consumers Have Many
Different Lifestyles

Lifestyles

They have many different
beliefs.

Can We Communicate?
Think Language first!
 Do we need an interpreter?
 Communicate respectfully.
 Be sensitive to the consumer and the family.
 Consider your dress, tone of voice, eye contact,
location, seating arrangement, privacy, etc.


Is our approach culturally
appropriate?
“What do you call your problem?”
“What name does it have?”
“What do you think caused your problem?”
“Why do you think it started when it did?”
From Arthur Kleinman’s question protocol in“Culture,Illness, and Care:
Clinical Lessons from Anthropologic and Cross Cultural Research”,
Ann.Intern.Med. 1978:Vol.88, pg.251-258

Important Issues to Consider…





Impact of religion.
How are women, men, elders, and children
treated in their culture?
Is there domestic violence?
Ethnic minorities generally underutilize
outpatient services, although African-Americans
are over-represented in inpatient setting.

Diagnosis






Minorities with Bipolar Disorder are often
diagnosed with schizophrenia. (Mukherjee,et al)
African Americans are over diagnosed with
schizophrenia and under diagnosed with mood
disorders. (Bell )
A mental health consumer’s addictions may not
be treated.
The elderly may not be assessed for substance
abuse or alcoholism.

Diagnosis
A person with a primary addiction problem
might not be treated for a co-occurring mental
illness.
 Learning disabilities may not be identified in
individuals with mental illness or substance
abuse.
 A person with mental retardation may not be
treated for mental illness or substance abuse.


Diagnosis
Post Traumatic Stress Disorder is often
undiagnosed in people suffering from
Domestic Abuse or other trauma.
 Children who are witnessing or are
victims of domestic abuse or another
trauma, may be misdiagnosed with
Attention Deficit Hyperactivity Disorder.


Medication Differences





Asians and Hispanics need lower doses of antipsychotics.
African Americans use the same doses of antipsychotics, but lower doses of lithium.
The elderly need lower dosages of medications.
Thus, metabolism of drugs varies with age and
ethnicity and is critical in prescribing
medications.

From “Making Room for Culture in Psychiatry” by Lin, et al.

Pain Tolerance
Men and women tolerate pain differently.
 Cultures tolerate pain differently.
 People with addictions develop a
hypersensitivity to pain.
 In certain cultures, self-inflicted pain is a
part of a religious experience.


Religion





Religious beliefs shape how the world is viewed.
Is illness a punishment? The devil’s work? An
evil spell? Bad karma?
For Hispanics, the curandero is a trusted healer.
For Lakota Sioux, the ritual Vision Quest,
praying and fasting at a holy site is life
changing.

Remember there are as many
differences
Between individuals in the same
culture as there are between
individuals in different cultures!

Two African American
families, one lesbian
and the other, multi-racial.

German Consumers
Suggestions from our Gillespie County MH staff

What generation German?
 Would they feel more comfortable
speaking in German?


A consumer reacting to internal stimuli.

German Consumers
Suggestions from our Gillespie MHC staff in Fredericksburg

They may be resistant to seeking
mental services.
They may be reluctant to take medication.
They may “keep things within the family.”
They are concerned about the stigma.

German Consumers
They may feel it’s a character flaw or a
disgrace.
 They are very concerned about
confidentiality.
 Drinking alcohol is an accepted part of
their culture.
 Teen drinking may be acceptable in their
family.


Hispanic Consumers
from the U.S. Census, 1/23/03 Houston Chronicle

Hispanics are the largest minority group in
the U.S. with 37 million people.
 Texas is approximately 32 percent
Hispanic
 11.5 % African American,
 3.3% Other
 53.1% Anglo


Treatment Issues for Hispanic
Consumers
Do we need an interpreter?
 Is the person Tejano or from Mexico?
What generation Hispanic?
Is the person using a curandero?

Treatment issues for Hispanic
Consumers
Hallucinations are natural in their
religion.
 Hearing the voice of a loved one or having
hallucinations might be an expectations
when celebrating the Day of the Dead.
 Hispanic families are patriarchal.


Hispanic Consumers and
The Day of the Dead
A man is dressed in a skeleton
costume to portray death
in a celebration of
Dia de los Muertos,
The Day of the Dead.
People visit the graves of their
dead relatives to honor them.

Native Americans

Treatment Issues for Native
American Consumers
 Impact of racism,unemployment,and poverty.
 Coping with reservation life and
assimilation in mainstream culture.
 Consider the obesity, diabetes,
hypertension, and alcoholism in adults
and fetal alcohol syndrome in children.
 High use of native healers in the Southwest.

African Americans

African Americans
from the Houston Chronicle, 1/23/03

There are 36.2 million Americans who
identify themselves as “black only.”
 37.7 million identify themselves as “black
and at least one other race.”
 11.5% of Texans are African Americans.


Treatment Issues for African
American
Assess for co-occurring substance use
disorders and alcoholism.
 Address complications of obesity,
hypertension, diabetes,congestive heart
failure, asthma, and cancer.
 Sickle cell anemia is another illness
specific to African Americans.


Treatment Issues for African
Americans
Matriarchy; Mom or grandmother are the
dominant family figures.
 Lack of male role models and intact
families.
 Extended family or the Church may be
supports.


Treatment Issues for African
Americans


There is discrimination within their own
group based on skin color, hair texture,
class, values, etc.

Treatment Issues for Asians

Asians rarely seek help until its very severe.
Asians have extremely low admissions to state hospitals.
Mental illness is considered shameful. It’s hidden.
Is an interpreter needed?

Treatment Issues for Asians
Focus on physical symptoms.
 Asians are sensitive to medication.
 Give ½ the standard dose.
 Asians may use traditional healers and
herbal medicine.
 Asians may “flush” when drinking
alcohol.


Asian Consumers

Acupuncture has been used to treat
pain, schizophrenia, depression, and addictions.

Treatment Issues for Asians
Asian Cultures are patriarchal.
 The males in the family have the authority.
 Asians are more formal and inhibited in
their social behavior.


Older Adults

Treatment Issues for Older
Adults
Are they aware they need help?

Treatment Issues for Older
Adults
Is their mental illness caused by medicine?
 Do their medical problems cause or
complicate their mental illness?
 Is there Elder Abuse?


Gay Men and Lesbian Women
May struggle with homophobia and“being in the
closet” at work and with their families.
Gay people may want marriage, children, partner
benefits, etc., but may endure legal barriers.

Gay and Lesbian Women
Gay people often have specific health
issues related to their sexual practices.
 HIV, AIDS and STD’s are still concerns
with Gay men.
 People may be grieving the death of a
partner or friends who’ve died from AIDS,
or coping with living with AIDS or being
HIV+ themselves.


Treatment Issues for Gay and
Lesbians
Explore childhood abuse issues and
Domestic Violence..
 Assess for substance use and alcoholism.
 Sex enhancing drug use may be common
among some gay men.


Physically Challenged
Can they get to treatment?
Deal with their frustration and depression
Re: their disability.
 Do they need vocational assistance?

Mentally Challenged

Treatment Issues of Mentally
Challenged
They need to have meaningful activity
and purpose in their lives.
 They need to feel acknowledged and
appreciated.
 They need safety, structure, and security.
 Lack of continuity can cause crisis!
 They may need vocational assistance.


Winona Ryder

December 12, 2001,
Winona Ryder shoplifted
$5,560.40 designer items
from Saks Fifth Avenue in
Beverley Hills.

Twice an Academy
Award Nominated
actress

She had the following 8 drugs in
her possession:
Liquid demerol
 Liquid Diazepam
 Vicodin
 Percodan
 Valium
 Morphine sulfate
 Endocet (containing Oxycodone)


Patterns of Drug Use are highly
Regional.
 Drugs,

routes of administration, street
names, patterns of use, and drug
combinations may differ greatly, not
only between individuals from
different cultures, but different parts
of the country or even different parts
of the city.

Drugs of Choice
Native Americans-alcohol
 Asians-gambling, work
 Gay Men-stimulants, amyl nitrate, ecstasy
 “Rich”-prescription drugs, Internet porn
 M.D.’s –Vicodin


Drugs of Choice
Young adults-marijuana, cigarettes
 Geriatrics-alcohol, pills
 Sex Workers-crack cocaine, IV speedballs
 Screen mentally retarded for abuse too!


How Do We Best Serve Our
Consumers?




Examine own stereotypes.
Build trust.
Use People First language!

How do we best serve our
consumers?
Pronounce the person’s name correctly.
 Get an interpreter, if necessary.
 Educate yourself from the consumer, his
family, co-workers, etc.
 Remember differences do matter!



Slide 47

Cultural Competence
Integrating Differences
into Community Services

Objectives
Understand Stigma.
 Understand Culture Competency.
 Learn Culturally competent care for
people with Mental Health, Mental
Retardation and Addictions.


We live in an world
which often separates us.
Racism
 Sexism
 Ageism
 Feminism
 Classism
 Atheism


“Different” people are
“Stigmatized”

Mentally retarded inmates in a sanitorium in Germany

Stigma
Definitions from the U. of Chicago PSR Training Manual

“Stigmas are negative attitudes about a
group that lead to depriving them of
some fair opportunities.”

Stigma is related to…..
Stereotypes
Prejudice
Discrimination

Stereotypes
from The Asian Health Coalition of Illinois

Stereotypes are exaggerated beliefs
or fixed ideas about a person or
group which is held by people and
sustained by selective perception and
selective forgetting.

Prejudice
from The Asian Health Coalition of Illinois

Prejudice is a preconceived idea or
negative attitude formed before the
facts are known and sustained over
generalizations. A bias without
reason, resisting all evidence…

Discrimination
from The Asian Health Coalition of Illinois

Discrimination refers to treatment in
favor or against a person based on
the group to which that person
belongs and not on merit.

Stigmatized People…..
Experience being stereotyped and
are often the object of
discrimination and prejudice.

People are often stigmatized by:













Mental Illness
Mental Retardation
Physical Disability (including blindness, deafness)
Alcoholism /and or Drug Addiction
HIV or AIDS, Cancer or other terminal illnesses
Criminal behavior
Poverty
Alternative Lifestyles/sexual orientation
Wheelchair bound
Gender
Obesity

All our Consumers belong to
stigmatized groups!

Stigmatized People
Consumers and their families
can’t navigate the bureaucracy
even if resources are there.
It’s too frustrating!

Use People First Language
“I am more than my
illness….Don’t call me
“the schizophrenic,
“the addict” or
“the retard.”

As human beings, we have many
similarities…..
But, who we really are, is often
derived from our original family of origin
and our current lifestyle.

The Bottom Line:
People are different, even within
their own culture!
These differences matter when
planning and providing services.

National Mental Health
Association
“For Mental Health consumers, both
access to the services and the effectiveness
of the care they receive are greatly affected
by the degree to which the delivery system
is“culturally competent.”

Some important definitions
Related to Cultural Competency

Culture

from King,et. al

The Office of Special Programs, U.S. Dept. of Education

“The integrated patterns of human
behavior that includes thoughts,
communications, actions, customs,
beliefs,values, and institutions of
racial, ethnic, religious, or social
groups.”

Cultural Sensitivity
An awareness and respect of a
person’s cultural beliefs and
values.
Culhane-Pera, et .al

Cultural Competency
 Skills

(that translate into)
 Behaviors, Practices, Attitudes, and
 Policies
That enable an individual, agency, or
system to effectively serve culturally
diverse communities.
from The Asian Health Coalition of Illinois

Here at Hill Country MHDDC
Consumers are very diverse in their
language and culture.

61% of our Consumers are
Caucasian Americans
Many have German
backgrounds.

Our Consumers are …..

n
1% NativeAmerican

33% Hispanic
1% Asian

3% African
American

1% are “Others”

Consumers Have Many
Different Lifestyles

Lifestyles

They have many different
beliefs.

Can We Communicate?
Think Language first!
 Do we need an interpreter?
 Communicate respectfully.
 Be sensitive to the consumer and the family.
 Consider your dress, tone of voice, eye contact,
location, seating arrangement, privacy, etc.


Is our approach culturally
appropriate?
“What do you call your problem?”
“What name does it have?”
“What do you think caused your problem?”
“Why do you think it started when it did?”
From Arthur Kleinman’s question protocol in“Culture,Illness, and Care:
Clinical Lessons from Anthropologic and Cross Cultural Research”,
Ann.Intern.Med. 1978:Vol.88, pg.251-258

Important Issues to Consider…





Impact of religion.
How are women, men, elders, and children
treated in their culture?
Is there domestic violence?
Ethnic minorities generally underutilize
outpatient services, although African-Americans
are over-represented in inpatient setting.

Diagnosis






Minorities with Bipolar Disorder are often
diagnosed with schizophrenia. (Mukherjee,et al)
African Americans are over diagnosed with
schizophrenia and under diagnosed with mood
disorders. (Bell )
A mental health consumer’s addictions may not
be treated.
The elderly may not be assessed for substance
abuse or alcoholism.

Diagnosis
A person with a primary addiction problem
might not be treated for a co-occurring mental
illness.
 Learning disabilities may not be identified in
individuals with mental illness or substance
abuse.
 A person with mental retardation may not be
treated for mental illness or substance abuse.


Diagnosis
Post Traumatic Stress Disorder is often
undiagnosed in people suffering from
Domestic Abuse or other trauma.
 Children who are witnessing or are
victims of domestic abuse or another
trauma, may be misdiagnosed with
Attention Deficit Hyperactivity Disorder.


Medication Differences





Asians and Hispanics need lower doses of antipsychotics.
African Americans use the same doses of antipsychotics, but lower doses of lithium.
The elderly need lower dosages of medications.
Thus, metabolism of drugs varies with age and
ethnicity and is critical in prescribing
medications.

From “Making Room for Culture in Psychiatry” by Lin, et al.

Pain Tolerance
Men and women tolerate pain differently.
 Cultures tolerate pain differently.
 People with addictions develop a
hypersensitivity to pain.
 In certain cultures, self-inflicted pain is a
part of a religious experience.


Religion





Religious beliefs shape how the world is viewed.
Is illness a punishment? The devil’s work? An
evil spell? Bad karma?
For Hispanics, the curandero is a trusted healer.
For Lakota Sioux, the ritual Vision Quest,
praying and fasting at a holy site is life
changing.

Remember there are as many
differences
Between individuals in the same
culture as there are between
individuals in different cultures!

Two African American
families, one lesbian
and the other, multi-racial.

German Consumers
Suggestions from our Gillespie County MH staff

What generation German?
 Would they feel more comfortable
speaking in German?


A consumer reacting to internal stimuli.

German Consumers
Suggestions from our Gillespie MHC staff in Fredericksburg

They may be resistant to seeking
mental services.
They may be reluctant to take medication.
They may “keep things within the family.”
They are concerned about the stigma.

German Consumers
They may feel it’s a character flaw or a
disgrace.
 They are very concerned about
confidentiality.
 Drinking alcohol is an accepted part of
their culture.
 Teen drinking may be acceptable in their
family.


Hispanic Consumers
from the U.S. Census, 1/23/03 Houston Chronicle

Hispanics are the largest minority group in
the U.S. with 37 million people.
 Texas is approximately 32 percent
Hispanic
 11.5 % African American,
 3.3% Other
 53.1% Anglo


Treatment Issues for Hispanic
Consumers
Do we need an interpreter?
 Is the person Tejano or from Mexico?
What generation Hispanic?
Is the person using a curandero?

Treatment issues for Hispanic
Consumers
Hallucinations are natural in their
religion.
 Hearing the voice of a loved one or having
hallucinations might be an expectations
when celebrating the Day of the Dead.
 Hispanic families are patriarchal.


Hispanic Consumers and
The Day of the Dead
A man is dressed in a skeleton
costume to portray death
in a celebration of
Dia de los Muertos,
The Day of the Dead.
People visit the graves of their
dead relatives to honor them.

Native Americans

Treatment Issues for Native
American Consumers
 Impact of racism,unemployment,and poverty.
 Coping with reservation life and
assimilation in mainstream culture.
 Consider the obesity, diabetes,
hypertension, and alcoholism in adults
and fetal alcohol syndrome in children.
 High use of native healers in the Southwest.

African Americans

African Americans
from the Houston Chronicle, 1/23/03

There are 36.2 million Americans who
identify themselves as “black only.”
 37.7 million identify themselves as “black
and at least one other race.”
 11.5% of Texans are African Americans.


Treatment Issues for African
American
Assess for co-occurring substance use
disorders and alcoholism.
 Address complications of obesity,
hypertension, diabetes,congestive heart
failure, asthma, and cancer.
 Sickle cell anemia is another illness
specific to African Americans.


Treatment Issues for African
Americans
Matriarchy; Mom or grandmother are the
dominant family figures.
 Lack of male role models and intact
families.
 Extended family or the Church may be
supports.


Treatment Issues for African
Americans


There is discrimination within their own
group based on skin color, hair texture,
class, values, etc.

Treatment Issues for Asians

Asians rarely seek help until its very severe.
Asians have extremely low admissions to state hospitals.
Mental illness is considered shameful. It’s hidden.
Is an interpreter needed?

Treatment Issues for Asians
Focus on physical symptoms.
 Asians are sensitive to medication.
 Give ½ the standard dose.
 Asians may use traditional healers and
herbal medicine.
 Asians may “flush” when drinking
alcohol.


Asian Consumers

Acupuncture has been used to treat
pain, schizophrenia, depression, and addictions.

Treatment Issues for Asians
Asian Cultures are patriarchal.
 The males in the family have the authority.
 Asians are more formal and inhibited in
their social behavior.


Older Adults

Treatment Issues for Older
Adults
Are they aware they need help?

Treatment Issues for Older
Adults
Is their mental illness caused by medicine?
 Do their medical problems cause or
complicate their mental illness?
 Is there Elder Abuse?


Gay Men and Lesbian Women
May struggle with homophobia and“being in the
closet” at work and with their families.
Gay people may want marriage, children, partner
benefits, etc., but may endure legal barriers.

Gay and Lesbian Women
Gay people often have specific health
issues related to their sexual practices.
 HIV, AIDS and STD’s are still concerns
with Gay men.
 People may be grieving the death of a
partner or friends who’ve died from AIDS,
or coping with living with AIDS or being
HIV+ themselves.


Treatment Issues for Gay and
Lesbians
Explore childhood abuse issues and
Domestic Violence..
 Assess for substance use and alcoholism.
 Sex enhancing drug use may be common
among some gay men.


Physically Challenged
Can they get to treatment?
Deal with their frustration and depression
Re: their disability.
 Do they need vocational assistance?

Mentally Challenged

Treatment Issues of Mentally
Challenged
They need to have meaningful activity
and purpose in their lives.
 They need to feel acknowledged and
appreciated.
 They need safety, structure, and security.
 Lack of continuity can cause crisis!
 They may need vocational assistance.


Winona Ryder

December 12, 2001,
Winona Ryder shoplifted
$5,560.40 designer items
from Saks Fifth Avenue in
Beverley Hills.

Twice an Academy
Award Nominated
actress

She had the following 8 drugs in
her possession:
Liquid demerol
 Liquid Diazepam
 Vicodin
 Percodan
 Valium
 Morphine sulfate
 Endocet (containing Oxycodone)


Patterns of Drug Use are highly
Regional.
 Drugs,

routes of administration, street
names, patterns of use, and drug
combinations may differ greatly, not
only between individuals from
different cultures, but different parts
of the country or even different parts
of the city.

Drugs of Choice
Native Americans-alcohol
 Asians-gambling, work
 Gay Men-stimulants, amyl nitrate, ecstasy
 “Rich”-prescription drugs, Internet porn
 M.D.’s –Vicodin


Drugs of Choice
Young adults-marijuana, cigarettes
 Geriatrics-alcohol, pills
 Sex Workers-crack cocaine, IV speedballs
 Screen mentally retarded for abuse too!


How Do We Best Serve Our
Consumers?




Examine own stereotypes.
Build trust.
Use People First language!

How do we best serve our
consumers?
Pronounce the person’s name correctly.
 Get an interpreter, if necessary.
 Educate yourself from the consumer, his
family, co-workers, etc.
 Remember differences do matter!



Slide 48

Cultural Competence
Integrating Differences
into Community Services

Objectives
Understand Stigma.
 Understand Culture Competency.
 Learn Culturally competent care for
people with Mental Health, Mental
Retardation and Addictions.


We live in an world
which often separates us.
Racism
 Sexism
 Ageism
 Feminism
 Classism
 Atheism


“Different” people are
“Stigmatized”

Mentally retarded inmates in a sanitorium in Germany

Stigma
Definitions from the U. of Chicago PSR Training Manual

“Stigmas are negative attitudes about a
group that lead to depriving them of
some fair opportunities.”

Stigma is related to…..
Stereotypes
Prejudice
Discrimination

Stereotypes
from The Asian Health Coalition of Illinois

Stereotypes are exaggerated beliefs
or fixed ideas about a person or
group which is held by people and
sustained by selective perception and
selective forgetting.

Prejudice
from The Asian Health Coalition of Illinois

Prejudice is a preconceived idea or
negative attitude formed before the
facts are known and sustained over
generalizations. A bias without
reason, resisting all evidence…

Discrimination
from The Asian Health Coalition of Illinois

Discrimination refers to treatment in
favor or against a person based on
the group to which that person
belongs and not on merit.

Stigmatized People…..
Experience being stereotyped and
are often the object of
discrimination and prejudice.

People are often stigmatized by:













Mental Illness
Mental Retardation
Physical Disability (including blindness, deafness)
Alcoholism /and or Drug Addiction
HIV or AIDS, Cancer or other terminal illnesses
Criminal behavior
Poverty
Alternative Lifestyles/sexual orientation
Wheelchair bound
Gender
Obesity

All our Consumers belong to
stigmatized groups!

Stigmatized People
Consumers and their families
can’t navigate the bureaucracy
even if resources are there.
It’s too frustrating!

Use People First Language
“I am more than my
illness….Don’t call me
“the schizophrenic,
“the addict” or
“the retard.”

As human beings, we have many
similarities…..
But, who we really are, is often
derived from our original family of origin
and our current lifestyle.

The Bottom Line:
People are different, even within
their own culture!
These differences matter when
planning and providing services.

National Mental Health
Association
“For Mental Health consumers, both
access to the services and the effectiveness
of the care they receive are greatly affected
by the degree to which the delivery system
is“culturally competent.”

Some important definitions
Related to Cultural Competency

Culture

from King,et. al

The Office of Special Programs, U.S. Dept. of Education

“The integrated patterns of human
behavior that includes thoughts,
communications, actions, customs,
beliefs,values, and institutions of
racial, ethnic, religious, or social
groups.”

Cultural Sensitivity
An awareness and respect of a
person’s cultural beliefs and
values.
Culhane-Pera, et .al

Cultural Competency
 Skills

(that translate into)
 Behaviors, Practices, Attitudes, and
 Policies
That enable an individual, agency, or
system to effectively serve culturally
diverse communities.
from The Asian Health Coalition of Illinois

Here at Hill Country MHDDC
Consumers are very diverse in their
language and culture.

61% of our Consumers are
Caucasian Americans
Many have German
backgrounds.

Our Consumers are …..

n
1% NativeAmerican

33% Hispanic
1% Asian

3% African
American

1% are “Others”

Consumers Have Many
Different Lifestyles

Lifestyles

They have many different
beliefs.

Can We Communicate?
Think Language first!
 Do we need an interpreter?
 Communicate respectfully.
 Be sensitive to the consumer and the family.
 Consider your dress, tone of voice, eye contact,
location, seating arrangement, privacy, etc.


Is our approach culturally
appropriate?
“What do you call your problem?”
“What name does it have?”
“What do you think caused your problem?”
“Why do you think it started when it did?”
From Arthur Kleinman’s question protocol in“Culture,Illness, and Care:
Clinical Lessons from Anthropologic and Cross Cultural Research”,
Ann.Intern.Med. 1978:Vol.88, pg.251-258

Important Issues to Consider…





Impact of religion.
How are women, men, elders, and children
treated in their culture?
Is there domestic violence?
Ethnic minorities generally underutilize
outpatient services, although African-Americans
are over-represented in inpatient setting.

Diagnosis






Minorities with Bipolar Disorder are often
diagnosed with schizophrenia. (Mukherjee,et al)
African Americans are over diagnosed with
schizophrenia and under diagnosed with mood
disorders. (Bell )
A mental health consumer’s addictions may not
be treated.
The elderly may not be assessed for substance
abuse or alcoholism.

Diagnosis
A person with a primary addiction problem
might not be treated for a co-occurring mental
illness.
 Learning disabilities may not be identified in
individuals with mental illness or substance
abuse.
 A person with mental retardation may not be
treated for mental illness or substance abuse.


Diagnosis
Post Traumatic Stress Disorder is often
undiagnosed in people suffering from
Domestic Abuse or other trauma.
 Children who are witnessing or are
victims of domestic abuse or another
trauma, may be misdiagnosed with
Attention Deficit Hyperactivity Disorder.


Medication Differences





Asians and Hispanics need lower doses of antipsychotics.
African Americans use the same doses of antipsychotics, but lower doses of lithium.
The elderly need lower dosages of medications.
Thus, metabolism of drugs varies with age and
ethnicity and is critical in prescribing
medications.

From “Making Room for Culture in Psychiatry” by Lin, et al.

Pain Tolerance
Men and women tolerate pain differently.
 Cultures tolerate pain differently.
 People with addictions develop a
hypersensitivity to pain.
 In certain cultures, self-inflicted pain is a
part of a religious experience.


Religion





Religious beliefs shape how the world is viewed.
Is illness a punishment? The devil’s work? An
evil spell? Bad karma?
For Hispanics, the curandero is a trusted healer.
For Lakota Sioux, the ritual Vision Quest,
praying and fasting at a holy site is life
changing.

Remember there are as many
differences
Between individuals in the same
culture as there are between
individuals in different cultures!

Two African American
families, one lesbian
and the other, multi-racial.

German Consumers
Suggestions from our Gillespie County MH staff

What generation German?
 Would they feel more comfortable
speaking in German?


A consumer reacting to internal stimuli.

German Consumers
Suggestions from our Gillespie MHC staff in Fredericksburg

They may be resistant to seeking
mental services.
They may be reluctant to take medication.
They may “keep things within the family.”
They are concerned about the stigma.

German Consumers
They may feel it’s a character flaw or a
disgrace.
 They are very concerned about
confidentiality.
 Drinking alcohol is an accepted part of
their culture.
 Teen drinking may be acceptable in their
family.


Hispanic Consumers
from the U.S. Census, 1/23/03 Houston Chronicle

Hispanics are the largest minority group in
the U.S. with 37 million people.
 Texas is approximately 32 percent
Hispanic
 11.5 % African American,
 3.3% Other
 53.1% Anglo


Treatment Issues for Hispanic
Consumers
Do we need an interpreter?
 Is the person Tejano or from Mexico?
What generation Hispanic?
Is the person using a curandero?

Treatment issues for Hispanic
Consumers
Hallucinations are natural in their
religion.
 Hearing the voice of a loved one or having
hallucinations might be an expectations
when celebrating the Day of the Dead.
 Hispanic families are patriarchal.


Hispanic Consumers and
The Day of the Dead
A man is dressed in a skeleton
costume to portray death
in a celebration of
Dia de los Muertos,
The Day of the Dead.
People visit the graves of their
dead relatives to honor them.

Native Americans

Treatment Issues for Native
American Consumers
 Impact of racism,unemployment,and poverty.
 Coping with reservation life and
assimilation in mainstream culture.
 Consider the obesity, diabetes,
hypertension, and alcoholism in adults
and fetal alcohol syndrome in children.
 High use of native healers in the Southwest.

African Americans

African Americans
from the Houston Chronicle, 1/23/03

There are 36.2 million Americans who
identify themselves as “black only.”
 37.7 million identify themselves as “black
and at least one other race.”
 11.5% of Texans are African Americans.


Treatment Issues for African
American
Assess for co-occurring substance use
disorders and alcoholism.
 Address complications of obesity,
hypertension, diabetes,congestive heart
failure, asthma, and cancer.
 Sickle cell anemia is another illness
specific to African Americans.


Treatment Issues for African
Americans
Matriarchy; Mom or grandmother are the
dominant family figures.
 Lack of male role models and intact
families.
 Extended family or the Church may be
supports.


Treatment Issues for African
Americans


There is discrimination within their own
group based on skin color, hair texture,
class, values, etc.

Treatment Issues for Asians

Asians rarely seek help until its very severe.
Asians have extremely low admissions to state hospitals.
Mental illness is considered shameful. It’s hidden.
Is an interpreter needed?

Treatment Issues for Asians
Focus on physical symptoms.
 Asians are sensitive to medication.
 Give ½ the standard dose.
 Asians may use traditional healers and
herbal medicine.
 Asians may “flush” when drinking
alcohol.


Asian Consumers

Acupuncture has been used to treat
pain, schizophrenia, depression, and addictions.

Treatment Issues for Asians
Asian Cultures are patriarchal.
 The males in the family have the authority.
 Asians are more formal and inhibited in
their social behavior.


Older Adults

Treatment Issues for Older
Adults
Are they aware they need help?

Treatment Issues for Older
Adults
Is their mental illness caused by medicine?
 Do their medical problems cause or
complicate their mental illness?
 Is there Elder Abuse?


Gay Men and Lesbian Women
May struggle with homophobia and“being in the
closet” at work and with their families.
Gay people may want marriage, children, partner
benefits, etc., but may endure legal barriers.

Gay and Lesbian Women
Gay people often have specific health
issues related to their sexual practices.
 HIV, AIDS and STD’s are still concerns
with Gay men.
 People may be grieving the death of a
partner or friends who’ve died from AIDS,
or coping with living with AIDS or being
HIV+ themselves.


Treatment Issues for Gay and
Lesbians
Explore childhood abuse issues and
Domestic Violence..
 Assess for substance use and alcoholism.
 Sex enhancing drug use may be common
among some gay men.


Physically Challenged
Can they get to treatment?
Deal with their frustration and depression
Re: their disability.
 Do they need vocational assistance?

Mentally Challenged

Treatment Issues of Mentally
Challenged
They need to have meaningful activity
and purpose in their lives.
 They need to feel acknowledged and
appreciated.
 They need safety, structure, and security.
 Lack of continuity can cause crisis!
 They may need vocational assistance.


Winona Ryder

December 12, 2001,
Winona Ryder shoplifted
$5,560.40 designer items
from Saks Fifth Avenue in
Beverley Hills.

Twice an Academy
Award Nominated
actress

She had the following 8 drugs in
her possession:
Liquid demerol
 Liquid Diazepam
 Vicodin
 Percodan
 Valium
 Morphine sulfate
 Endocet (containing Oxycodone)


Patterns of Drug Use are highly
Regional.
 Drugs,

routes of administration, street
names, patterns of use, and drug
combinations may differ greatly, not
only between individuals from
different cultures, but different parts
of the country or even different parts
of the city.

Drugs of Choice
Native Americans-alcohol
 Asians-gambling, work
 Gay Men-stimulants, amyl nitrate, ecstasy
 “Rich”-prescription drugs, Internet porn
 M.D.’s –Vicodin


Drugs of Choice
Young adults-marijuana, cigarettes
 Geriatrics-alcohol, pills
 Sex Workers-crack cocaine, IV speedballs
 Screen mentally retarded for abuse too!


How Do We Best Serve Our
Consumers?




Examine own stereotypes.
Build trust.
Use People First language!

How do we best serve our
consumers?
Pronounce the person’s name correctly.
 Get an interpreter, if necessary.
 Educate yourself from the consumer, his
family, co-workers, etc.
 Remember differences do matter!



Slide 49

Cultural Competence
Integrating Differences
into Community Services

Objectives
Understand Stigma.
 Understand Culture Competency.
 Learn Culturally competent care for
people with Mental Health, Mental
Retardation and Addictions.


We live in an world
which often separates us.
Racism
 Sexism
 Ageism
 Feminism
 Classism
 Atheism


“Different” people are
“Stigmatized”

Mentally retarded inmates in a sanitorium in Germany

Stigma
Definitions from the U. of Chicago PSR Training Manual

“Stigmas are negative attitudes about a
group that lead to depriving them of
some fair opportunities.”

Stigma is related to…..
Stereotypes
Prejudice
Discrimination

Stereotypes
from The Asian Health Coalition of Illinois

Stereotypes are exaggerated beliefs
or fixed ideas about a person or
group which is held by people and
sustained by selective perception and
selective forgetting.

Prejudice
from The Asian Health Coalition of Illinois

Prejudice is a preconceived idea or
negative attitude formed before the
facts are known and sustained over
generalizations. A bias without
reason, resisting all evidence…

Discrimination
from The Asian Health Coalition of Illinois

Discrimination refers to treatment in
favor or against a person based on
the group to which that person
belongs and not on merit.

Stigmatized People…..
Experience being stereotyped and
are often the object of
discrimination and prejudice.

People are often stigmatized by:













Mental Illness
Mental Retardation
Physical Disability (including blindness, deafness)
Alcoholism /and or Drug Addiction
HIV or AIDS, Cancer or other terminal illnesses
Criminal behavior
Poverty
Alternative Lifestyles/sexual orientation
Wheelchair bound
Gender
Obesity

All our Consumers belong to
stigmatized groups!

Stigmatized People
Consumers and their families
can’t navigate the bureaucracy
even if resources are there.
It’s too frustrating!

Use People First Language
“I am more than my
illness….Don’t call me
“the schizophrenic,
“the addict” or
“the retard.”

As human beings, we have many
similarities…..
But, who we really are, is often
derived from our original family of origin
and our current lifestyle.

The Bottom Line:
People are different, even within
their own culture!
These differences matter when
planning and providing services.

National Mental Health
Association
“For Mental Health consumers, both
access to the services and the effectiveness
of the care they receive are greatly affected
by the degree to which the delivery system
is“culturally competent.”

Some important definitions
Related to Cultural Competency

Culture

from King,et. al

The Office of Special Programs, U.S. Dept. of Education

“The integrated patterns of human
behavior that includes thoughts,
communications, actions, customs,
beliefs,values, and institutions of
racial, ethnic, religious, or social
groups.”

Cultural Sensitivity
An awareness and respect of a
person’s cultural beliefs and
values.
Culhane-Pera, et .al

Cultural Competency
 Skills

(that translate into)
 Behaviors, Practices, Attitudes, and
 Policies
That enable an individual, agency, or
system to effectively serve culturally
diverse communities.
from The Asian Health Coalition of Illinois

Here at Hill Country MHDDC
Consumers are very diverse in their
language and culture.

61% of our Consumers are
Caucasian Americans
Many have German
backgrounds.

Our Consumers are …..

n
1% NativeAmerican

33% Hispanic
1% Asian

3% African
American

1% are “Others”

Consumers Have Many
Different Lifestyles

Lifestyles

They have many different
beliefs.

Can We Communicate?
Think Language first!
 Do we need an interpreter?
 Communicate respectfully.
 Be sensitive to the consumer and the family.
 Consider your dress, tone of voice, eye contact,
location, seating arrangement, privacy, etc.


Is our approach culturally
appropriate?
“What do you call your problem?”
“What name does it have?”
“What do you think caused your problem?”
“Why do you think it started when it did?”
From Arthur Kleinman’s question protocol in“Culture,Illness, and Care:
Clinical Lessons from Anthropologic and Cross Cultural Research”,
Ann.Intern.Med. 1978:Vol.88, pg.251-258

Important Issues to Consider…





Impact of religion.
How are women, men, elders, and children
treated in their culture?
Is there domestic violence?
Ethnic minorities generally underutilize
outpatient services, although African-Americans
are over-represented in inpatient setting.

Diagnosis






Minorities with Bipolar Disorder are often
diagnosed with schizophrenia. (Mukherjee,et al)
African Americans are over diagnosed with
schizophrenia and under diagnosed with mood
disorders. (Bell )
A mental health consumer’s addictions may not
be treated.
The elderly may not be assessed for substance
abuse or alcoholism.

Diagnosis
A person with a primary addiction problem
might not be treated for a co-occurring mental
illness.
 Learning disabilities may not be identified in
individuals with mental illness or substance
abuse.
 A person with mental retardation may not be
treated for mental illness or substance abuse.


Diagnosis
Post Traumatic Stress Disorder is often
undiagnosed in people suffering from
Domestic Abuse or other trauma.
 Children who are witnessing or are
victims of domestic abuse or another
trauma, may be misdiagnosed with
Attention Deficit Hyperactivity Disorder.


Medication Differences





Asians and Hispanics need lower doses of antipsychotics.
African Americans use the same doses of antipsychotics, but lower doses of lithium.
The elderly need lower dosages of medications.
Thus, metabolism of drugs varies with age and
ethnicity and is critical in prescribing
medications.

From “Making Room for Culture in Psychiatry” by Lin, et al.

Pain Tolerance
Men and women tolerate pain differently.
 Cultures tolerate pain differently.
 People with addictions develop a
hypersensitivity to pain.
 In certain cultures, self-inflicted pain is a
part of a religious experience.


Religion





Religious beliefs shape how the world is viewed.
Is illness a punishment? The devil’s work? An
evil spell? Bad karma?
For Hispanics, the curandero is a trusted healer.
For Lakota Sioux, the ritual Vision Quest,
praying and fasting at a holy site is life
changing.

Remember there are as many
differences
Between individuals in the same
culture as there are between
individuals in different cultures!

Two African American
families, one lesbian
and the other, multi-racial.

German Consumers
Suggestions from our Gillespie County MH staff

What generation German?
 Would they feel more comfortable
speaking in German?


A consumer reacting to internal stimuli.

German Consumers
Suggestions from our Gillespie MHC staff in Fredericksburg

They may be resistant to seeking
mental services.
They may be reluctant to take medication.
They may “keep things within the family.”
They are concerned about the stigma.

German Consumers
They may feel it’s a character flaw or a
disgrace.
 They are very concerned about
confidentiality.
 Drinking alcohol is an accepted part of
their culture.
 Teen drinking may be acceptable in their
family.


Hispanic Consumers
from the U.S. Census, 1/23/03 Houston Chronicle

Hispanics are the largest minority group in
the U.S. with 37 million people.
 Texas is approximately 32 percent
Hispanic
 11.5 % African American,
 3.3% Other
 53.1% Anglo


Treatment Issues for Hispanic
Consumers
Do we need an interpreter?
 Is the person Tejano or from Mexico?
What generation Hispanic?
Is the person using a curandero?

Treatment issues for Hispanic
Consumers
Hallucinations are natural in their
religion.
 Hearing the voice of a loved one or having
hallucinations might be an expectations
when celebrating the Day of the Dead.
 Hispanic families are patriarchal.


Hispanic Consumers and
The Day of the Dead
A man is dressed in a skeleton
costume to portray death
in a celebration of
Dia de los Muertos,
The Day of the Dead.
People visit the graves of their
dead relatives to honor them.

Native Americans

Treatment Issues for Native
American Consumers
 Impact of racism,unemployment,and poverty.
 Coping with reservation life and
assimilation in mainstream culture.
 Consider the obesity, diabetes,
hypertension, and alcoholism in adults
and fetal alcohol syndrome in children.
 High use of native healers in the Southwest.

African Americans

African Americans
from the Houston Chronicle, 1/23/03

There are 36.2 million Americans who
identify themselves as “black only.”
 37.7 million identify themselves as “black
and at least one other race.”
 11.5% of Texans are African Americans.


Treatment Issues for African
American
Assess for co-occurring substance use
disorders and alcoholism.
 Address complications of obesity,
hypertension, diabetes,congestive heart
failure, asthma, and cancer.
 Sickle cell anemia is another illness
specific to African Americans.


Treatment Issues for African
Americans
Matriarchy; Mom or grandmother are the
dominant family figures.
 Lack of male role models and intact
families.
 Extended family or the Church may be
supports.


Treatment Issues for African
Americans


There is discrimination within their own
group based on skin color, hair texture,
class, values, etc.

Treatment Issues for Asians

Asians rarely seek help until its very severe.
Asians have extremely low admissions to state hospitals.
Mental illness is considered shameful. It’s hidden.
Is an interpreter needed?

Treatment Issues for Asians
Focus on physical symptoms.
 Asians are sensitive to medication.
 Give ½ the standard dose.
 Asians may use traditional healers and
herbal medicine.
 Asians may “flush” when drinking
alcohol.


Asian Consumers

Acupuncture has been used to treat
pain, schizophrenia, depression, and addictions.

Treatment Issues for Asians
Asian Cultures are patriarchal.
 The males in the family have the authority.
 Asians are more formal and inhibited in
their social behavior.


Older Adults

Treatment Issues for Older
Adults
Are they aware they need help?

Treatment Issues for Older
Adults
Is their mental illness caused by medicine?
 Do their medical problems cause or
complicate their mental illness?
 Is there Elder Abuse?


Gay Men and Lesbian Women
May struggle with homophobia and“being in the
closet” at work and with their families.
Gay people may want marriage, children, partner
benefits, etc., but may endure legal barriers.

Gay and Lesbian Women
Gay people often have specific health
issues related to their sexual practices.
 HIV, AIDS and STD’s are still concerns
with Gay men.
 People may be grieving the death of a
partner or friends who’ve died from AIDS,
or coping with living with AIDS or being
HIV+ themselves.


Treatment Issues for Gay and
Lesbians
Explore childhood abuse issues and
Domestic Violence..
 Assess for substance use and alcoholism.
 Sex enhancing drug use may be common
among some gay men.


Physically Challenged
Can they get to treatment?
Deal with their frustration and depression
Re: their disability.
 Do they need vocational assistance?

Mentally Challenged

Treatment Issues of Mentally
Challenged
They need to have meaningful activity
and purpose in their lives.
 They need to feel acknowledged and
appreciated.
 They need safety, structure, and security.
 Lack of continuity can cause crisis!
 They may need vocational assistance.


Winona Ryder

December 12, 2001,
Winona Ryder shoplifted
$5,560.40 designer items
from Saks Fifth Avenue in
Beverley Hills.

Twice an Academy
Award Nominated
actress

She had the following 8 drugs in
her possession:
Liquid demerol
 Liquid Diazepam
 Vicodin
 Percodan
 Valium
 Morphine sulfate
 Endocet (containing Oxycodone)


Patterns of Drug Use are highly
Regional.
 Drugs,

routes of administration, street
names, patterns of use, and drug
combinations may differ greatly, not
only between individuals from
different cultures, but different parts
of the country or even different parts
of the city.

Drugs of Choice
Native Americans-alcohol
 Asians-gambling, work
 Gay Men-stimulants, amyl nitrate, ecstasy
 “Rich”-prescription drugs, Internet porn
 M.D.’s –Vicodin


Drugs of Choice
Young adults-marijuana, cigarettes
 Geriatrics-alcohol, pills
 Sex Workers-crack cocaine, IV speedballs
 Screen mentally retarded for abuse too!


How Do We Best Serve Our
Consumers?




Examine own stereotypes.
Build trust.
Use People First language!

How do we best serve our
consumers?
Pronounce the person’s name correctly.
 Get an interpreter, if necessary.
 Educate yourself from the consumer, his
family, co-workers, etc.
 Remember differences do matter!



Slide 50

Cultural Competence
Integrating Differences
into Community Services

Objectives
Understand Stigma.
 Understand Culture Competency.
 Learn Culturally competent care for
people with Mental Health, Mental
Retardation and Addictions.


We live in an world
which often separates us.
Racism
 Sexism
 Ageism
 Feminism
 Classism
 Atheism


“Different” people are
“Stigmatized”

Mentally retarded inmates in a sanitorium in Germany

Stigma
Definitions from the U. of Chicago PSR Training Manual

“Stigmas are negative attitudes about a
group that lead to depriving them of
some fair opportunities.”

Stigma is related to…..
Stereotypes
Prejudice
Discrimination

Stereotypes
from The Asian Health Coalition of Illinois

Stereotypes are exaggerated beliefs
or fixed ideas about a person or
group which is held by people and
sustained by selective perception and
selective forgetting.

Prejudice
from The Asian Health Coalition of Illinois

Prejudice is a preconceived idea or
negative attitude formed before the
facts are known and sustained over
generalizations. A bias without
reason, resisting all evidence…

Discrimination
from The Asian Health Coalition of Illinois

Discrimination refers to treatment in
favor or against a person based on
the group to which that person
belongs and not on merit.

Stigmatized People…..
Experience being stereotyped and
are often the object of
discrimination and prejudice.

People are often stigmatized by:













Mental Illness
Mental Retardation
Physical Disability (including blindness, deafness)
Alcoholism /and or Drug Addiction
HIV or AIDS, Cancer or other terminal illnesses
Criminal behavior
Poverty
Alternative Lifestyles/sexual orientation
Wheelchair bound
Gender
Obesity

All our Consumers belong to
stigmatized groups!

Stigmatized People
Consumers and their families
can’t navigate the bureaucracy
even if resources are there.
It’s too frustrating!

Use People First Language
“I am more than my
illness….Don’t call me
“the schizophrenic,
“the addict” or
“the retard.”

As human beings, we have many
similarities…..
But, who we really are, is often
derived from our original family of origin
and our current lifestyle.

The Bottom Line:
People are different, even within
their own culture!
These differences matter when
planning and providing services.

National Mental Health
Association
“For Mental Health consumers, both
access to the services and the effectiveness
of the care they receive are greatly affected
by the degree to which the delivery system
is“culturally competent.”

Some important definitions
Related to Cultural Competency

Culture

from King,et. al

The Office of Special Programs, U.S. Dept. of Education

“The integrated patterns of human
behavior that includes thoughts,
communications, actions, customs,
beliefs,values, and institutions of
racial, ethnic, religious, or social
groups.”

Cultural Sensitivity
An awareness and respect of a
person’s cultural beliefs and
values.
Culhane-Pera, et .al

Cultural Competency
 Skills

(that translate into)
 Behaviors, Practices, Attitudes, and
 Policies
That enable an individual, agency, or
system to effectively serve culturally
diverse communities.
from The Asian Health Coalition of Illinois

Here at Hill Country MHDDC
Consumers are very diverse in their
language and culture.

61% of our Consumers are
Caucasian Americans
Many have German
backgrounds.

Our Consumers are …..

n
1% NativeAmerican

33% Hispanic
1% Asian

3% African
American

1% are “Others”

Consumers Have Many
Different Lifestyles

Lifestyles

They have many different
beliefs.

Can We Communicate?
Think Language first!
 Do we need an interpreter?
 Communicate respectfully.
 Be sensitive to the consumer and the family.
 Consider your dress, tone of voice, eye contact,
location, seating arrangement, privacy, etc.


Is our approach culturally
appropriate?
“What do you call your problem?”
“What name does it have?”
“What do you think caused your problem?”
“Why do you think it started when it did?”
From Arthur Kleinman’s question protocol in“Culture,Illness, and Care:
Clinical Lessons from Anthropologic and Cross Cultural Research”,
Ann.Intern.Med. 1978:Vol.88, pg.251-258

Important Issues to Consider…





Impact of religion.
How are women, men, elders, and children
treated in their culture?
Is there domestic violence?
Ethnic minorities generally underutilize
outpatient services, although African-Americans
are over-represented in inpatient setting.

Diagnosis






Minorities with Bipolar Disorder are often
diagnosed with schizophrenia. (Mukherjee,et al)
African Americans are over diagnosed with
schizophrenia and under diagnosed with mood
disorders. (Bell )
A mental health consumer’s addictions may not
be treated.
The elderly may not be assessed for substance
abuse or alcoholism.

Diagnosis
A person with a primary addiction problem
might not be treated for a co-occurring mental
illness.
 Learning disabilities may not be identified in
individuals with mental illness or substance
abuse.
 A person with mental retardation may not be
treated for mental illness or substance abuse.


Diagnosis
Post Traumatic Stress Disorder is often
undiagnosed in people suffering from
Domestic Abuse or other trauma.
 Children who are witnessing or are
victims of domestic abuse or another
trauma, may be misdiagnosed with
Attention Deficit Hyperactivity Disorder.


Medication Differences





Asians and Hispanics need lower doses of antipsychotics.
African Americans use the same doses of antipsychotics, but lower doses of lithium.
The elderly need lower dosages of medications.
Thus, metabolism of drugs varies with age and
ethnicity and is critical in prescribing
medications.

From “Making Room for Culture in Psychiatry” by Lin, et al.

Pain Tolerance
Men and women tolerate pain differently.
 Cultures tolerate pain differently.
 People with addictions develop a
hypersensitivity to pain.
 In certain cultures, self-inflicted pain is a
part of a religious experience.


Religion





Religious beliefs shape how the world is viewed.
Is illness a punishment? The devil’s work? An
evil spell? Bad karma?
For Hispanics, the curandero is a trusted healer.
For Lakota Sioux, the ritual Vision Quest,
praying and fasting at a holy site is life
changing.

Remember there are as many
differences
Between individuals in the same
culture as there are between
individuals in different cultures!

Two African American
families, one lesbian
and the other, multi-racial.

German Consumers
Suggestions from our Gillespie County MH staff

What generation German?
 Would they feel more comfortable
speaking in German?


A consumer reacting to internal stimuli.

German Consumers
Suggestions from our Gillespie MHC staff in Fredericksburg

They may be resistant to seeking
mental services.
They may be reluctant to take medication.
They may “keep things within the family.”
They are concerned about the stigma.

German Consumers
They may feel it’s a character flaw or a
disgrace.
 They are very concerned about
confidentiality.
 Drinking alcohol is an accepted part of
their culture.
 Teen drinking may be acceptable in their
family.


Hispanic Consumers
from the U.S. Census, 1/23/03 Houston Chronicle

Hispanics are the largest minority group in
the U.S. with 37 million people.
 Texas is approximately 32 percent
Hispanic
 11.5 % African American,
 3.3% Other
 53.1% Anglo


Treatment Issues for Hispanic
Consumers
Do we need an interpreter?
 Is the person Tejano or from Mexico?
What generation Hispanic?
Is the person using a curandero?

Treatment issues for Hispanic
Consumers
Hallucinations are natural in their
religion.
 Hearing the voice of a loved one or having
hallucinations might be an expectations
when celebrating the Day of the Dead.
 Hispanic families are patriarchal.


Hispanic Consumers and
The Day of the Dead
A man is dressed in a skeleton
costume to portray death
in a celebration of
Dia de los Muertos,
The Day of the Dead.
People visit the graves of their
dead relatives to honor them.

Native Americans

Treatment Issues for Native
American Consumers
 Impact of racism,unemployment,and poverty.
 Coping with reservation life and
assimilation in mainstream culture.
 Consider the obesity, diabetes,
hypertension, and alcoholism in adults
and fetal alcohol syndrome in children.
 High use of native healers in the Southwest.

African Americans

African Americans
from the Houston Chronicle, 1/23/03

There are 36.2 million Americans who
identify themselves as “black only.”
 37.7 million identify themselves as “black
and at least one other race.”
 11.5% of Texans are African Americans.


Treatment Issues for African
American
Assess for co-occurring substance use
disorders and alcoholism.
 Address complications of obesity,
hypertension, diabetes,congestive heart
failure, asthma, and cancer.
 Sickle cell anemia is another illness
specific to African Americans.


Treatment Issues for African
Americans
Matriarchy; Mom or grandmother are the
dominant family figures.
 Lack of male role models and intact
families.
 Extended family or the Church may be
supports.


Treatment Issues for African
Americans


There is discrimination within their own
group based on skin color, hair texture,
class, values, etc.

Treatment Issues for Asians

Asians rarely seek help until its very severe.
Asians have extremely low admissions to state hospitals.
Mental illness is considered shameful. It’s hidden.
Is an interpreter needed?

Treatment Issues for Asians
Focus on physical symptoms.
 Asians are sensitive to medication.
 Give ½ the standard dose.
 Asians may use traditional healers and
herbal medicine.
 Asians may “flush” when drinking
alcohol.


Asian Consumers

Acupuncture has been used to treat
pain, schizophrenia, depression, and addictions.

Treatment Issues for Asians
Asian Cultures are patriarchal.
 The males in the family have the authority.
 Asians are more formal and inhibited in
their social behavior.


Older Adults

Treatment Issues for Older
Adults
Are they aware they need help?

Treatment Issues for Older
Adults
Is their mental illness caused by medicine?
 Do their medical problems cause or
complicate their mental illness?
 Is there Elder Abuse?


Gay Men and Lesbian Women
May struggle with homophobia and“being in the
closet” at work and with their families.
Gay people may want marriage, children, partner
benefits, etc., but may endure legal barriers.

Gay and Lesbian Women
Gay people often have specific health
issues related to their sexual practices.
 HIV, AIDS and STD’s are still concerns
with Gay men.
 People may be grieving the death of a
partner or friends who’ve died from AIDS,
or coping with living with AIDS or being
HIV+ themselves.


Treatment Issues for Gay and
Lesbians
Explore childhood abuse issues and
Domestic Violence..
 Assess for substance use and alcoholism.
 Sex enhancing drug use may be common
among some gay men.


Physically Challenged
Can they get to treatment?
Deal with their frustration and depression
Re: their disability.
 Do they need vocational assistance?

Mentally Challenged

Treatment Issues of Mentally
Challenged
They need to have meaningful activity
and purpose in their lives.
 They need to feel acknowledged and
appreciated.
 They need safety, structure, and security.
 Lack of continuity can cause crisis!
 They may need vocational assistance.


Winona Ryder

December 12, 2001,
Winona Ryder shoplifted
$5,560.40 designer items
from Saks Fifth Avenue in
Beverley Hills.

Twice an Academy
Award Nominated
actress

She had the following 8 drugs in
her possession:
Liquid demerol
 Liquid Diazepam
 Vicodin
 Percodan
 Valium
 Morphine sulfate
 Endocet (containing Oxycodone)


Patterns of Drug Use are highly
Regional.
 Drugs,

routes of administration, street
names, patterns of use, and drug
combinations may differ greatly, not
only between individuals from
different cultures, but different parts
of the country or even different parts
of the city.

Drugs of Choice
Native Americans-alcohol
 Asians-gambling, work
 Gay Men-stimulants, amyl nitrate, ecstasy
 “Rich”-prescription drugs, Internet porn
 M.D.’s –Vicodin


Drugs of Choice
Young adults-marijuana, cigarettes
 Geriatrics-alcohol, pills
 Sex Workers-crack cocaine, IV speedballs
 Screen mentally retarded for abuse too!


How Do We Best Serve Our
Consumers?




Examine own stereotypes.
Build trust.
Use People First language!

How do we best serve our
consumers?
Pronounce the person’s name correctly.
 Get an interpreter, if necessary.
 Educate yourself from the consumer, his
family, co-workers, etc.
 Remember differences do matter!



Slide 51

Cultural Competence
Integrating Differences
into Community Services

Objectives
Understand Stigma.
 Understand Culture Competency.
 Learn Culturally competent care for
people with Mental Health, Mental
Retardation and Addictions.


We live in an world
which often separates us.
Racism
 Sexism
 Ageism
 Feminism
 Classism
 Atheism


“Different” people are
“Stigmatized”

Mentally retarded inmates in a sanitorium in Germany

Stigma
Definitions from the U. of Chicago PSR Training Manual

“Stigmas are negative attitudes about a
group that lead to depriving them of
some fair opportunities.”

Stigma is related to…..
Stereotypes
Prejudice
Discrimination

Stereotypes
from The Asian Health Coalition of Illinois

Stereotypes are exaggerated beliefs
or fixed ideas about a person or
group which is held by people and
sustained by selective perception and
selective forgetting.

Prejudice
from The Asian Health Coalition of Illinois

Prejudice is a preconceived idea or
negative attitude formed before the
facts are known and sustained over
generalizations. A bias without
reason, resisting all evidence…

Discrimination
from The Asian Health Coalition of Illinois

Discrimination refers to treatment in
favor or against a person based on
the group to which that person
belongs and not on merit.

Stigmatized People…..
Experience being stereotyped and
are often the object of
discrimination and prejudice.

People are often stigmatized by:













Mental Illness
Mental Retardation
Physical Disability (including blindness, deafness)
Alcoholism /and or Drug Addiction
HIV or AIDS, Cancer or other terminal illnesses
Criminal behavior
Poverty
Alternative Lifestyles/sexual orientation
Wheelchair bound
Gender
Obesity

All our Consumers belong to
stigmatized groups!

Stigmatized People
Consumers and their families
can’t navigate the bureaucracy
even if resources are there.
It’s too frustrating!

Use People First Language
“I am more than my
illness….Don’t call me
“the schizophrenic,
“the addict” or
“the retard.”

As human beings, we have many
similarities…..
But, who we really are, is often
derived from our original family of origin
and our current lifestyle.

The Bottom Line:
People are different, even within
their own culture!
These differences matter when
planning and providing services.

National Mental Health
Association
“For Mental Health consumers, both
access to the services and the effectiveness
of the care they receive are greatly affected
by the degree to which the delivery system
is“culturally competent.”

Some important definitions
Related to Cultural Competency

Culture

from King,et. al

The Office of Special Programs, U.S. Dept. of Education

“The integrated patterns of human
behavior that includes thoughts,
communications, actions, customs,
beliefs,values, and institutions of
racial, ethnic, religious, or social
groups.”

Cultural Sensitivity
An awareness and respect of a
person’s cultural beliefs and
values.
Culhane-Pera, et .al

Cultural Competency
 Skills

(that translate into)
 Behaviors, Practices, Attitudes, and
 Policies
That enable an individual, agency, or
system to effectively serve culturally
diverse communities.
from The Asian Health Coalition of Illinois

Here at Hill Country MHDDC
Consumers are very diverse in their
language and culture.

61% of our Consumers are
Caucasian Americans
Many have German
backgrounds.

Our Consumers are …..

n
1% NativeAmerican

33% Hispanic
1% Asian

3% African
American

1% are “Others”

Consumers Have Many
Different Lifestyles

Lifestyles

They have many different
beliefs.

Can We Communicate?
Think Language first!
 Do we need an interpreter?
 Communicate respectfully.
 Be sensitive to the consumer and the family.
 Consider your dress, tone of voice, eye contact,
location, seating arrangement, privacy, etc.


Is our approach culturally
appropriate?
“What do you call your problem?”
“What name does it have?”
“What do you think caused your problem?”
“Why do you think it started when it did?”
From Arthur Kleinman’s question protocol in“Culture,Illness, and Care:
Clinical Lessons from Anthropologic and Cross Cultural Research”,
Ann.Intern.Med. 1978:Vol.88, pg.251-258

Important Issues to Consider…





Impact of religion.
How are women, men, elders, and children
treated in their culture?
Is there domestic violence?
Ethnic minorities generally underutilize
outpatient services, although African-Americans
are over-represented in inpatient setting.

Diagnosis






Minorities with Bipolar Disorder are often
diagnosed with schizophrenia. (Mukherjee,et al)
African Americans are over diagnosed with
schizophrenia and under diagnosed with mood
disorders. (Bell )
A mental health consumer’s addictions may not
be treated.
The elderly may not be assessed for substance
abuse or alcoholism.

Diagnosis
A person with a primary addiction problem
might not be treated for a co-occurring mental
illness.
 Learning disabilities may not be identified in
individuals with mental illness or substance
abuse.
 A person with mental retardation may not be
treated for mental illness or substance abuse.


Diagnosis
Post Traumatic Stress Disorder is often
undiagnosed in people suffering from
Domestic Abuse or other trauma.
 Children who are witnessing or are
victims of domestic abuse or another
trauma, may be misdiagnosed with
Attention Deficit Hyperactivity Disorder.


Medication Differences





Asians and Hispanics need lower doses of antipsychotics.
African Americans use the same doses of antipsychotics, but lower doses of lithium.
The elderly need lower dosages of medications.
Thus, metabolism of drugs varies with age and
ethnicity and is critical in prescribing
medications.

From “Making Room for Culture in Psychiatry” by Lin, et al.

Pain Tolerance
Men and women tolerate pain differently.
 Cultures tolerate pain differently.
 People with addictions develop a
hypersensitivity to pain.
 In certain cultures, self-inflicted pain is a
part of a religious experience.


Religion





Religious beliefs shape how the world is viewed.
Is illness a punishment? The devil’s work? An
evil spell? Bad karma?
For Hispanics, the curandero is a trusted healer.
For Lakota Sioux, the ritual Vision Quest,
praying and fasting at a holy site is life
changing.

Remember there are as many
differences
Between individuals in the same
culture as there are between
individuals in different cultures!

Two African American
families, one lesbian
and the other, multi-racial.

German Consumers
Suggestions from our Gillespie County MH staff

What generation German?
 Would they feel more comfortable
speaking in German?


A consumer reacting to internal stimuli.

German Consumers
Suggestions from our Gillespie MHC staff in Fredericksburg

They may be resistant to seeking
mental services.
They may be reluctant to take medication.
They may “keep things within the family.”
They are concerned about the stigma.

German Consumers
They may feel it’s a character flaw or a
disgrace.
 They are very concerned about
confidentiality.
 Drinking alcohol is an accepted part of
their culture.
 Teen drinking may be acceptable in their
family.


Hispanic Consumers
from the U.S. Census, 1/23/03 Houston Chronicle

Hispanics are the largest minority group in
the U.S. with 37 million people.
 Texas is approximately 32 percent
Hispanic
 11.5 % African American,
 3.3% Other
 53.1% Anglo


Treatment Issues for Hispanic
Consumers
Do we need an interpreter?
 Is the person Tejano or from Mexico?
What generation Hispanic?
Is the person using a curandero?

Treatment issues for Hispanic
Consumers
Hallucinations are natural in their
religion.
 Hearing the voice of a loved one or having
hallucinations might be an expectations
when celebrating the Day of the Dead.
 Hispanic families are patriarchal.


Hispanic Consumers and
The Day of the Dead
A man is dressed in a skeleton
costume to portray death
in a celebration of
Dia de los Muertos,
The Day of the Dead.
People visit the graves of their
dead relatives to honor them.

Native Americans

Treatment Issues for Native
American Consumers
 Impact of racism,unemployment,and poverty.
 Coping with reservation life and
assimilation in mainstream culture.
 Consider the obesity, diabetes,
hypertension, and alcoholism in adults
and fetal alcohol syndrome in children.
 High use of native healers in the Southwest.

African Americans

African Americans
from the Houston Chronicle, 1/23/03

There are 36.2 million Americans who
identify themselves as “black only.”
 37.7 million identify themselves as “black
and at least one other race.”
 11.5% of Texans are African Americans.


Treatment Issues for African
American
Assess for co-occurring substance use
disorders and alcoholism.
 Address complications of obesity,
hypertension, diabetes,congestive heart
failure, asthma, and cancer.
 Sickle cell anemia is another illness
specific to African Americans.


Treatment Issues for African
Americans
Matriarchy; Mom or grandmother are the
dominant family figures.
 Lack of male role models and intact
families.
 Extended family or the Church may be
supports.


Treatment Issues for African
Americans


There is discrimination within their own
group based on skin color, hair texture,
class, values, etc.

Treatment Issues for Asians

Asians rarely seek help until its very severe.
Asians have extremely low admissions to state hospitals.
Mental illness is considered shameful. It’s hidden.
Is an interpreter needed?

Treatment Issues for Asians
Focus on physical symptoms.
 Asians are sensitive to medication.
 Give ½ the standard dose.
 Asians may use traditional healers and
herbal medicine.
 Asians may “flush” when drinking
alcohol.


Asian Consumers

Acupuncture has been used to treat
pain, schizophrenia, depression, and addictions.

Treatment Issues for Asians
Asian Cultures are patriarchal.
 The males in the family have the authority.
 Asians are more formal and inhibited in
their social behavior.


Older Adults

Treatment Issues for Older
Adults
Are they aware they need help?

Treatment Issues for Older
Adults
Is their mental illness caused by medicine?
 Do their medical problems cause or
complicate their mental illness?
 Is there Elder Abuse?


Gay Men and Lesbian Women
May struggle with homophobia and“being in the
closet” at work and with their families.
Gay people may want marriage, children, partner
benefits, etc., but may endure legal barriers.

Gay and Lesbian Women
Gay people often have specific health
issues related to their sexual practices.
 HIV, AIDS and STD’s are still concerns
with Gay men.
 People may be grieving the death of a
partner or friends who’ve died from AIDS,
or coping with living with AIDS or being
HIV+ themselves.


Treatment Issues for Gay and
Lesbians
Explore childhood abuse issues and
Domestic Violence..
 Assess for substance use and alcoholism.
 Sex enhancing drug use may be common
among some gay men.


Physically Challenged
Can they get to treatment?
Deal with their frustration and depression
Re: their disability.
 Do they need vocational assistance?

Mentally Challenged

Treatment Issues of Mentally
Challenged
They need to have meaningful activity
and purpose in their lives.
 They need to feel acknowledged and
appreciated.
 They need safety, structure, and security.
 Lack of continuity can cause crisis!
 They may need vocational assistance.


Winona Ryder

December 12, 2001,
Winona Ryder shoplifted
$5,560.40 designer items
from Saks Fifth Avenue in
Beverley Hills.

Twice an Academy
Award Nominated
actress

She had the following 8 drugs in
her possession:
Liquid demerol
 Liquid Diazepam
 Vicodin
 Percodan
 Valium
 Morphine sulfate
 Endocet (containing Oxycodone)


Patterns of Drug Use are highly
Regional.
 Drugs,

routes of administration, street
names, patterns of use, and drug
combinations may differ greatly, not
only between individuals from
different cultures, but different parts
of the country or even different parts
of the city.

Drugs of Choice
Native Americans-alcohol
 Asians-gambling, work
 Gay Men-stimulants, amyl nitrate, ecstasy
 “Rich”-prescription drugs, Internet porn
 M.D.’s –Vicodin


Drugs of Choice
Young adults-marijuana, cigarettes
 Geriatrics-alcohol, pills
 Sex Workers-crack cocaine, IV speedballs
 Screen mentally retarded for abuse too!


How Do We Best Serve Our
Consumers?




Examine own stereotypes.
Build trust.
Use People First language!

How do we best serve our
consumers?
Pronounce the person’s name correctly.
 Get an interpreter, if necessary.
 Educate yourself from the consumer, his
family, co-workers, etc.
 Remember differences do matter!



Slide 52

Cultural Competence
Integrating Differences
into Community Services

Objectives
Understand Stigma.
 Understand Culture Competency.
 Learn Culturally competent care for
people with Mental Health, Mental
Retardation and Addictions.


We live in an world
which often separates us.
Racism
 Sexism
 Ageism
 Feminism
 Classism
 Atheism


“Different” people are
“Stigmatized”

Mentally retarded inmates in a sanitorium in Germany

Stigma
Definitions from the U. of Chicago PSR Training Manual

“Stigmas are negative attitudes about a
group that lead to depriving them of
some fair opportunities.”

Stigma is related to…..
Stereotypes
Prejudice
Discrimination

Stereotypes
from The Asian Health Coalition of Illinois

Stereotypes are exaggerated beliefs
or fixed ideas about a person or
group which is held by people and
sustained by selective perception and
selective forgetting.

Prejudice
from The Asian Health Coalition of Illinois

Prejudice is a preconceived idea or
negative attitude formed before the
facts are known and sustained over
generalizations. A bias without
reason, resisting all evidence…

Discrimination
from The Asian Health Coalition of Illinois

Discrimination refers to treatment in
favor or against a person based on
the group to which that person
belongs and not on merit.

Stigmatized People…..
Experience being stereotyped and
are often the object of
discrimination and prejudice.

People are often stigmatized by:













Mental Illness
Mental Retardation
Physical Disability (including blindness, deafness)
Alcoholism /and or Drug Addiction
HIV or AIDS, Cancer or other terminal illnesses
Criminal behavior
Poverty
Alternative Lifestyles/sexual orientation
Wheelchair bound
Gender
Obesity

All our Consumers belong to
stigmatized groups!

Stigmatized People
Consumers and their families
can’t navigate the bureaucracy
even if resources are there.
It’s too frustrating!

Use People First Language
“I am more than my
illness….Don’t call me
“the schizophrenic,
“the addict” or
“the retard.”

As human beings, we have many
similarities…..
But, who we really are, is often
derived from our original family of origin
and our current lifestyle.

The Bottom Line:
People are different, even within
their own culture!
These differences matter when
planning and providing services.

National Mental Health
Association
“For Mental Health consumers, both
access to the services and the effectiveness
of the care they receive are greatly affected
by the degree to which the delivery system
is“culturally competent.”

Some important definitions
Related to Cultural Competency

Culture

from King,et. al

The Office of Special Programs, U.S. Dept. of Education

“The integrated patterns of human
behavior that includes thoughts,
communications, actions, customs,
beliefs,values, and institutions of
racial, ethnic, religious, or social
groups.”

Cultural Sensitivity
An awareness and respect of a
person’s cultural beliefs and
values.
Culhane-Pera, et .al

Cultural Competency
 Skills

(that translate into)
 Behaviors, Practices, Attitudes, and
 Policies
That enable an individual, agency, or
system to effectively serve culturally
diverse communities.
from The Asian Health Coalition of Illinois

Here at Hill Country MHDDC
Consumers are very diverse in their
language and culture.

61% of our Consumers are
Caucasian Americans
Many have German
backgrounds.

Our Consumers are …..

n
1% NativeAmerican

33% Hispanic
1% Asian

3% African
American

1% are “Others”

Consumers Have Many
Different Lifestyles

Lifestyles

They have many different
beliefs.

Can We Communicate?
Think Language first!
 Do we need an interpreter?
 Communicate respectfully.
 Be sensitive to the consumer and the family.
 Consider your dress, tone of voice, eye contact,
location, seating arrangement, privacy, etc.


Is our approach culturally
appropriate?
“What do you call your problem?”
“What name does it have?”
“What do you think caused your problem?”
“Why do you think it started when it did?”
From Arthur Kleinman’s question protocol in“Culture,Illness, and Care:
Clinical Lessons from Anthropologic and Cross Cultural Research”,
Ann.Intern.Med. 1978:Vol.88, pg.251-258

Important Issues to Consider…





Impact of religion.
How are women, men, elders, and children
treated in their culture?
Is there domestic violence?
Ethnic minorities generally underutilize
outpatient services, although African-Americans
are over-represented in inpatient setting.

Diagnosis






Minorities with Bipolar Disorder are often
diagnosed with schizophrenia. (Mukherjee,et al)
African Americans are over diagnosed with
schizophrenia and under diagnosed with mood
disorders. (Bell )
A mental health consumer’s addictions may not
be treated.
The elderly may not be assessed for substance
abuse or alcoholism.

Diagnosis
A person with a primary addiction problem
might not be treated for a co-occurring mental
illness.
 Learning disabilities may not be identified in
individuals with mental illness or substance
abuse.
 A person with mental retardation may not be
treated for mental illness or substance abuse.


Diagnosis
Post Traumatic Stress Disorder is often
undiagnosed in people suffering from
Domestic Abuse or other trauma.
 Children who are witnessing or are
victims of domestic abuse or another
trauma, may be misdiagnosed with
Attention Deficit Hyperactivity Disorder.


Medication Differences





Asians and Hispanics need lower doses of antipsychotics.
African Americans use the same doses of antipsychotics, but lower doses of lithium.
The elderly need lower dosages of medications.
Thus, metabolism of drugs varies with age and
ethnicity and is critical in prescribing
medications.

From “Making Room for Culture in Psychiatry” by Lin, et al.

Pain Tolerance
Men and women tolerate pain differently.
 Cultures tolerate pain differently.
 People with addictions develop a
hypersensitivity to pain.
 In certain cultures, self-inflicted pain is a
part of a religious experience.


Religion





Religious beliefs shape how the world is viewed.
Is illness a punishment? The devil’s work? An
evil spell? Bad karma?
For Hispanics, the curandero is a trusted healer.
For Lakota Sioux, the ritual Vision Quest,
praying and fasting at a holy site is life
changing.

Remember there are as many
differences
Between individuals in the same
culture as there are between
individuals in different cultures!

Two African American
families, one lesbian
and the other, multi-racial.

German Consumers
Suggestions from our Gillespie County MH staff

What generation German?
 Would they feel more comfortable
speaking in German?


A consumer reacting to internal stimuli.

German Consumers
Suggestions from our Gillespie MHC staff in Fredericksburg

They may be resistant to seeking
mental services.
They may be reluctant to take medication.
They may “keep things within the family.”
They are concerned about the stigma.

German Consumers
They may feel it’s a character flaw or a
disgrace.
 They are very concerned about
confidentiality.
 Drinking alcohol is an accepted part of
their culture.
 Teen drinking may be acceptable in their
family.


Hispanic Consumers
from the U.S. Census, 1/23/03 Houston Chronicle

Hispanics are the largest minority group in
the U.S. with 37 million people.
 Texas is approximately 32 percent
Hispanic
 11.5 % African American,
 3.3% Other
 53.1% Anglo


Treatment Issues for Hispanic
Consumers
Do we need an interpreter?
 Is the person Tejano or from Mexico?
What generation Hispanic?
Is the person using a curandero?

Treatment issues for Hispanic
Consumers
Hallucinations are natural in their
religion.
 Hearing the voice of a loved one or having
hallucinations might be an expectations
when celebrating the Day of the Dead.
 Hispanic families are patriarchal.


Hispanic Consumers and
The Day of the Dead
A man is dressed in a skeleton
costume to portray death
in a celebration of
Dia de los Muertos,
The Day of the Dead.
People visit the graves of their
dead relatives to honor them.

Native Americans

Treatment Issues for Native
American Consumers
 Impact of racism,unemployment,and poverty.
 Coping with reservation life and
assimilation in mainstream culture.
 Consider the obesity, diabetes,
hypertension, and alcoholism in adults
and fetal alcohol syndrome in children.
 High use of native healers in the Southwest.

African Americans

African Americans
from the Houston Chronicle, 1/23/03

There are 36.2 million Americans who
identify themselves as “black only.”
 37.7 million identify themselves as “black
and at least one other race.”
 11.5% of Texans are African Americans.


Treatment Issues for African
American
Assess for co-occurring substance use
disorders and alcoholism.
 Address complications of obesity,
hypertension, diabetes,congestive heart
failure, asthma, and cancer.
 Sickle cell anemia is another illness
specific to African Americans.


Treatment Issues for African
Americans
Matriarchy; Mom or grandmother are the
dominant family figures.
 Lack of male role models and intact
families.
 Extended family or the Church may be
supports.


Treatment Issues for African
Americans


There is discrimination within their own
group based on skin color, hair texture,
class, values, etc.

Treatment Issues for Asians

Asians rarely seek help until its very severe.
Asians have extremely low admissions to state hospitals.
Mental illness is considered shameful. It’s hidden.
Is an interpreter needed?

Treatment Issues for Asians
Focus on physical symptoms.
 Asians are sensitive to medication.
 Give ½ the standard dose.
 Asians may use traditional healers and
herbal medicine.
 Asians may “flush” when drinking
alcohol.


Asian Consumers

Acupuncture has been used to treat
pain, schizophrenia, depression, and addictions.

Treatment Issues for Asians
Asian Cultures are patriarchal.
 The males in the family have the authority.
 Asians are more formal and inhibited in
their social behavior.


Older Adults

Treatment Issues for Older
Adults
Are they aware they need help?

Treatment Issues for Older
Adults
Is their mental illness caused by medicine?
 Do their medical problems cause or
complicate their mental illness?
 Is there Elder Abuse?


Gay Men and Lesbian Women
May struggle with homophobia and“being in the
closet” at work and with their families.
Gay people may want marriage, children, partner
benefits, etc., but may endure legal barriers.

Gay and Lesbian Women
Gay people often have specific health
issues related to their sexual practices.
 HIV, AIDS and STD’s are still concerns
with Gay men.
 People may be grieving the death of a
partner or friends who’ve died from AIDS,
or coping with living with AIDS or being
HIV+ themselves.


Treatment Issues for Gay and
Lesbians
Explore childhood abuse issues and
Domestic Violence..
 Assess for substance use and alcoholism.
 Sex enhancing drug use may be common
among some gay men.


Physically Challenged
Can they get to treatment?
Deal with their frustration and depression
Re: their disability.
 Do they need vocational assistance?

Mentally Challenged

Treatment Issues of Mentally
Challenged
They need to have meaningful activity
and purpose in their lives.
 They need to feel acknowledged and
appreciated.
 They need safety, structure, and security.
 Lack of continuity can cause crisis!
 They may need vocational assistance.


Winona Ryder

December 12, 2001,
Winona Ryder shoplifted
$5,560.40 designer items
from Saks Fifth Avenue in
Beverley Hills.

Twice an Academy
Award Nominated
actress

She had the following 8 drugs in
her possession:
Liquid demerol
 Liquid Diazepam
 Vicodin
 Percodan
 Valium
 Morphine sulfate
 Endocet (containing Oxycodone)


Patterns of Drug Use are highly
Regional.
 Drugs,

routes of administration, street
names, patterns of use, and drug
combinations may differ greatly, not
only between individuals from
different cultures, but different parts
of the country or even different parts
of the city.

Drugs of Choice
Native Americans-alcohol
 Asians-gambling, work
 Gay Men-stimulants, amyl nitrate, ecstasy
 “Rich”-prescription drugs, Internet porn
 M.D.’s –Vicodin


Drugs of Choice
Young adults-marijuana, cigarettes
 Geriatrics-alcohol, pills
 Sex Workers-crack cocaine, IV speedballs
 Screen mentally retarded for abuse too!


How Do We Best Serve Our
Consumers?




Examine own stereotypes.
Build trust.
Use People First language!

How do we best serve our
consumers?
Pronounce the person’s name correctly.
 Get an interpreter, if necessary.
 Educate yourself from the consumer, his
family, co-workers, etc.
 Remember differences do matter!



Slide 53

Cultural Competence
Integrating Differences
into Community Services

Objectives
Understand Stigma.
 Understand Culture Competency.
 Learn Culturally competent care for
people with Mental Health, Mental
Retardation and Addictions.


We live in an world
which often separates us.
Racism
 Sexism
 Ageism
 Feminism
 Classism
 Atheism


“Different” people are
“Stigmatized”

Mentally retarded inmates in a sanitorium in Germany

Stigma
Definitions from the U. of Chicago PSR Training Manual

“Stigmas are negative attitudes about a
group that lead to depriving them of
some fair opportunities.”

Stigma is related to…..
Stereotypes
Prejudice
Discrimination

Stereotypes
from The Asian Health Coalition of Illinois

Stereotypes are exaggerated beliefs
or fixed ideas about a person or
group which is held by people and
sustained by selective perception and
selective forgetting.

Prejudice
from The Asian Health Coalition of Illinois

Prejudice is a preconceived idea or
negative attitude formed before the
facts are known and sustained over
generalizations. A bias without
reason, resisting all evidence…

Discrimination
from The Asian Health Coalition of Illinois

Discrimination refers to treatment in
favor or against a person based on
the group to which that person
belongs and not on merit.

Stigmatized People…..
Experience being stereotyped and
are often the object of
discrimination and prejudice.

People are often stigmatized by:













Mental Illness
Mental Retardation
Physical Disability (including blindness, deafness)
Alcoholism /and or Drug Addiction
HIV or AIDS, Cancer or other terminal illnesses
Criminal behavior
Poverty
Alternative Lifestyles/sexual orientation
Wheelchair bound
Gender
Obesity

All our Consumers belong to
stigmatized groups!

Stigmatized People
Consumers and their families
can’t navigate the bureaucracy
even if resources are there.
It’s too frustrating!

Use People First Language
“I am more than my
illness….Don’t call me
“the schizophrenic,
“the addict” or
“the retard.”

As human beings, we have many
similarities…..
But, who we really are, is often
derived from our original family of origin
and our current lifestyle.

The Bottom Line:
People are different, even within
their own culture!
These differences matter when
planning and providing services.

National Mental Health
Association
“For Mental Health consumers, both
access to the services and the effectiveness
of the care they receive are greatly affected
by the degree to which the delivery system
is“culturally competent.”

Some important definitions
Related to Cultural Competency

Culture

from King,et. al

The Office of Special Programs, U.S. Dept. of Education

“The integrated patterns of human
behavior that includes thoughts,
communications, actions, customs,
beliefs,values, and institutions of
racial, ethnic, religious, or social
groups.”

Cultural Sensitivity
An awareness and respect of a
person’s cultural beliefs and
values.
Culhane-Pera, et .al

Cultural Competency
 Skills

(that translate into)
 Behaviors, Practices, Attitudes, and
 Policies
That enable an individual, agency, or
system to effectively serve culturally
diverse communities.
from The Asian Health Coalition of Illinois

Here at Hill Country MHDDC
Consumers are very diverse in their
language and culture.

61% of our Consumers are
Caucasian Americans
Many have German
backgrounds.

Our Consumers are …..

n
1% NativeAmerican

33% Hispanic
1% Asian

3% African
American

1% are “Others”

Consumers Have Many
Different Lifestyles

Lifestyles

They have many different
beliefs.

Can We Communicate?
Think Language first!
 Do we need an interpreter?
 Communicate respectfully.
 Be sensitive to the consumer and the family.
 Consider your dress, tone of voice, eye contact,
location, seating arrangement, privacy, etc.


Is our approach culturally
appropriate?
“What do you call your problem?”
“What name does it have?”
“What do you think caused your problem?”
“Why do you think it started when it did?”
From Arthur Kleinman’s question protocol in“Culture,Illness, and Care:
Clinical Lessons from Anthropologic and Cross Cultural Research”,
Ann.Intern.Med. 1978:Vol.88, pg.251-258

Important Issues to Consider…





Impact of religion.
How are women, men, elders, and children
treated in their culture?
Is there domestic violence?
Ethnic minorities generally underutilize
outpatient services, although African-Americans
are over-represented in inpatient setting.

Diagnosis






Minorities with Bipolar Disorder are often
diagnosed with schizophrenia. (Mukherjee,et al)
African Americans are over diagnosed with
schizophrenia and under diagnosed with mood
disorders. (Bell )
A mental health consumer’s addictions may not
be treated.
The elderly may not be assessed for substance
abuse or alcoholism.

Diagnosis
A person with a primary addiction problem
might not be treated for a co-occurring mental
illness.
 Learning disabilities may not be identified in
individuals with mental illness or substance
abuse.
 A person with mental retardation may not be
treated for mental illness or substance abuse.


Diagnosis
Post Traumatic Stress Disorder is often
undiagnosed in people suffering from
Domestic Abuse or other trauma.
 Children who are witnessing or are
victims of domestic abuse or another
trauma, may be misdiagnosed with
Attention Deficit Hyperactivity Disorder.


Medication Differences





Asians and Hispanics need lower doses of antipsychotics.
African Americans use the same doses of antipsychotics, but lower doses of lithium.
The elderly need lower dosages of medications.
Thus, metabolism of drugs varies with age and
ethnicity and is critical in prescribing
medications.

From “Making Room for Culture in Psychiatry” by Lin, et al.

Pain Tolerance
Men and women tolerate pain differently.
 Cultures tolerate pain differently.
 People with addictions develop a
hypersensitivity to pain.
 In certain cultures, self-inflicted pain is a
part of a religious experience.


Religion





Religious beliefs shape how the world is viewed.
Is illness a punishment? The devil’s work? An
evil spell? Bad karma?
For Hispanics, the curandero is a trusted healer.
For Lakota Sioux, the ritual Vision Quest,
praying and fasting at a holy site is life
changing.

Remember there are as many
differences
Between individuals in the same
culture as there are between
individuals in different cultures!

Two African American
families, one lesbian
and the other, multi-racial.

German Consumers
Suggestions from our Gillespie County MH staff

What generation German?
 Would they feel more comfortable
speaking in German?


A consumer reacting to internal stimuli.

German Consumers
Suggestions from our Gillespie MHC staff in Fredericksburg

They may be resistant to seeking
mental services.
They may be reluctant to take medication.
They may “keep things within the family.”
They are concerned about the stigma.

German Consumers
They may feel it’s a character flaw or a
disgrace.
 They are very concerned about
confidentiality.
 Drinking alcohol is an accepted part of
their culture.
 Teen drinking may be acceptable in their
family.


Hispanic Consumers
from the U.S. Census, 1/23/03 Houston Chronicle

Hispanics are the largest minority group in
the U.S. with 37 million people.
 Texas is approximately 32 percent
Hispanic
 11.5 % African American,
 3.3% Other
 53.1% Anglo


Treatment Issues for Hispanic
Consumers
Do we need an interpreter?
 Is the person Tejano or from Mexico?
What generation Hispanic?
Is the person using a curandero?

Treatment issues for Hispanic
Consumers
Hallucinations are natural in their
religion.
 Hearing the voice of a loved one or having
hallucinations might be an expectations
when celebrating the Day of the Dead.
 Hispanic families are patriarchal.


Hispanic Consumers and
The Day of the Dead
A man is dressed in a skeleton
costume to portray death
in a celebration of
Dia de los Muertos,
The Day of the Dead.
People visit the graves of their
dead relatives to honor them.

Native Americans

Treatment Issues for Native
American Consumers
 Impact of racism,unemployment,and poverty.
 Coping with reservation life and
assimilation in mainstream culture.
 Consider the obesity, diabetes,
hypertension, and alcoholism in adults
and fetal alcohol syndrome in children.
 High use of native healers in the Southwest.

African Americans

African Americans
from the Houston Chronicle, 1/23/03

There are 36.2 million Americans who
identify themselves as “black only.”
 37.7 million identify themselves as “black
and at least one other race.”
 11.5% of Texans are African Americans.


Treatment Issues for African
American
Assess for co-occurring substance use
disorders and alcoholism.
 Address complications of obesity,
hypertension, diabetes,congestive heart
failure, asthma, and cancer.
 Sickle cell anemia is another illness
specific to African Americans.


Treatment Issues for African
Americans
Matriarchy; Mom or grandmother are the
dominant family figures.
 Lack of male role models and intact
families.
 Extended family or the Church may be
supports.


Treatment Issues for African
Americans


There is discrimination within their own
group based on skin color, hair texture,
class, values, etc.

Treatment Issues for Asians

Asians rarely seek help until its very severe.
Asians have extremely low admissions to state hospitals.
Mental illness is considered shameful. It’s hidden.
Is an interpreter needed?

Treatment Issues for Asians
Focus on physical symptoms.
 Asians are sensitive to medication.
 Give ½ the standard dose.
 Asians may use traditional healers and
herbal medicine.
 Asians may “flush” when drinking
alcohol.


Asian Consumers

Acupuncture has been used to treat
pain, schizophrenia, depression, and addictions.

Treatment Issues for Asians
Asian Cultures are patriarchal.
 The males in the family have the authority.
 Asians are more formal and inhibited in
their social behavior.


Older Adults

Treatment Issues for Older
Adults
Are they aware they need help?

Treatment Issues for Older
Adults
Is their mental illness caused by medicine?
 Do their medical problems cause or
complicate their mental illness?
 Is there Elder Abuse?


Gay Men and Lesbian Women
May struggle with homophobia and“being in the
closet” at work and with their families.
Gay people may want marriage, children, partner
benefits, etc., but may endure legal barriers.

Gay and Lesbian Women
Gay people often have specific health
issues related to their sexual practices.
 HIV, AIDS and STD’s are still concerns
with Gay men.
 People may be grieving the death of a
partner or friends who’ve died from AIDS,
or coping with living with AIDS or being
HIV+ themselves.


Treatment Issues for Gay and
Lesbians
Explore childhood abuse issues and
Domestic Violence..
 Assess for substance use and alcoholism.
 Sex enhancing drug use may be common
among some gay men.


Physically Challenged
Can they get to treatment?
Deal with their frustration and depression
Re: their disability.
 Do they need vocational assistance?

Mentally Challenged

Treatment Issues of Mentally
Challenged
They need to have meaningful activity
and purpose in their lives.
 They need to feel acknowledged and
appreciated.
 They need safety, structure, and security.
 Lack of continuity can cause crisis!
 They may need vocational assistance.


Winona Ryder

December 12, 2001,
Winona Ryder shoplifted
$5,560.40 designer items
from Saks Fifth Avenue in
Beverley Hills.

Twice an Academy
Award Nominated
actress

She had the following 8 drugs in
her possession:
Liquid demerol
 Liquid Diazepam
 Vicodin
 Percodan
 Valium
 Morphine sulfate
 Endocet (containing Oxycodone)


Patterns of Drug Use are highly
Regional.
 Drugs,

routes of administration, street
names, patterns of use, and drug
combinations may differ greatly, not
only between individuals from
different cultures, but different parts
of the country or even different parts
of the city.

Drugs of Choice
Native Americans-alcohol
 Asians-gambling, work
 Gay Men-stimulants, amyl nitrate, ecstasy
 “Rich”-prescription drugs, Internet porn
 M.D.’s –Vicodin


Drugs of Choice
Young adults-marijuana, cigarettes
 Geriatrics-alcohol, pills
 Sex Workers-crack cocaine, IV speedballs
 Screen mentally retarded for abuse too!


How Do We Best Serve Our
Consumers?




Examine own stereotypes.
Build trust.
Use People First language!

How do we best serve our
consumers?
Pronounce the person’s name correctly.
 Get an interpreter, if necessary.
 Educate yourself from the consumer, his
family, co-workers, etc.
 Remember differences do matter!



Slide 54

Cultural Competence
Integrating Differences
into Community Services

Objectives
Understand Stigma.
 Understand Culture Competency.
 Learn Culturally competent care for
people with Mental Health, Mental
Retardation and Addictions.


We live in an world
which often separates us.
Racism
 Sexism
 Ageism
 Feminism
 Classism
 Atheism


“Different” people are
“Stigmatized”

Mentally retarded inmates in a sanitorium in Germany

Stigma
Definitions from the U. of Chicago PSR Training Manual

“Stigmas are negative attitudes about a
group that lead to depriving them of
some fair opportunities.”

Stigma is related to…..
Stereotypes
Prejudice
Discrimination

Stereotypes
from The Asian Health Coalition of Illinois

Stereotypes are exaggerated beliefs
or fixed ideas about a person or
group which is held by people and
sustained by selective perception and
selective forgetting.

Prejudice
from The Asian Health Coalition of Illinois

Prejudice is a preconceived idea or
negative attitude formed before the
facts are known and sustained over
generalizations. A bias without
reason, resisting all evidence…

Discrimination
from The Asian Health Coalition of Illinois

Discrimination refers to treatment in
favor or against a person based on
the group to which that person
belongs and not on merit.

Stigmatized People…..
Experience being stereotyped and
are often the object of
discrimination and prejudice.

People are often stigmatized by:













Mental Illness
Mental Retardation
Physical Disability (including blindness, deafness)
Alcoholism /and or Drug Addiction
HIV or AIDS, Cancer or other terminal illnesses
Criminal behavior
Poverty
Alternative Lifestyles/sexual orientation
Wheelchair bound
Gender
Obesity

All our Consumers belong to
stigmatized groups!

Stigmatized People
Consumers and their families
can’t navigate the bureaucracy
even if resources are there.
It’s too frustrating!

Use People First Language
“I am more than my
illness….Don’t call me
“the schizophrenic,
“the addict” or
“the retard.”

As human beings, we have many
similarities…..
But, who we really are, is often
derived from our original family of origin
and our current lifestyle.

The Bottom Line:
People are different, even within
their own culture!
These differences matter when
planning and providing services.

National Mental Health
Association
“For Mental Health consumers, both
access to the services and the effectiveness
of the care they receive are greatly affected
by the degree to which the delivery system
is“culturally competent.”

Some important definitions
Related to Cultural Competency

Culture

from King,et. al

The Office of Special Programs, U.S. Dept. of Education

“The integrated patterns of human
behavior that includes thoughts,
communications, actions, customs,
beliefs,values, and institutions of
racial, ethnic, religious, or social
groups.”

Cultural Sensitivity
An awareness and respect of a
person’s cultural beliefs and
values.
Culhane-Pera, et .al

Cultural Competency
 Skills

(that translate into)
 Behaviors, Practices, Attitudes, and
 Policies
That enable an individual, agency, or
system to effectively serve culturally
diverse communities.
from The Asian Health Coalition of Illinois

Here at Hill Country MHDDC
Consumers are very diverse in their
language and culture.

61% of our Consumers are
Caucasian Americans
Many have German
backgrounds.

Our Consumers are …..

n
1% NativeAmerican

33% Hispanic
1% Asian

3% African
American

1% are “Others”

Consumers Have Many
Different Lifestyles

Lifestyles

They have many different
beliefs.

Can We Communicate?
Think Language first!
 Do we need an interpreter?
 Communicate respectfully.
 Be sensitive to the consumer and the family.
 Consider your dress, tone of voice, eye contact,
location, seating arrangement, privacy, etc.


Is our approach culturally
appropriate?
“What do you call your problem?”
“What name does it have?”
“What do you think caused your problem?”
“Why do you think it started when it did?”
From Arthur Kleinman’s question protocol in“Culture,Illness, and Care:
Clinical Lessons from Anthropologic and Cross Cultural Research”,
Ann.Intern.Med. 1978:Vol.88, pg.251-258

Important Issues to Consider…





Impact of religion.
How are women, men, elders, and children
treated in their culture?
Is there domestic violence?
Ethnic minorities generally underutilize
outpatient services, although African-Americans
are over-represented in inpatient setting.

Diagnosis






Minorities with Bipolar Disorder are often
diagnosed with schizophrenia. (Mukherjee,et al)
African Americans are over diagnosed with
schizophrenia and under diagnosed with mood
disorders. (Bell )
A mental health consumer’s addictions may not
be treated.
The elderly may not be assessed for substance
abuse or alcoholism.

Diagnosis
A person with a primary addiction problem
might not be treated for a co-occurring mental
illness.
 Learning disabilities may not be identified in
individuals with mental illness or substance
abuse.
 A person with mental retardation may not be
treated for mental illness or substance abuse.


Diagnosis
Post Traumatic Stress Disorder is often
undiagnosed in people suffering from
Domestic Abuse or other trauma.
 Children who are witnessing or are
victims of domestic abuse or another
trauma, may be misdiagnosed with
Attention Deficit Hyperactivity Disorder.


Medication Differences





Asians and Hispanics need lower doses of antipsychotics.
African Americans use the same doses of antipsychotics, but lower doses of lithium.
The elderly need lower dosages of medications.
Thus, metabolism of drugs varies with age and
ethnicity and is critical in prescribing
medications.

From “Making Room for Culture in Psychiatry” by Lin, et al.

Pain Tolerance
Men and women tolerate pain differently.
 Cultures tolerate pain differently.
 People with addictions develop a
hypersensitivity to pain.
 In certain cultures, self-inflicted pain is a
part of a religious experience.


Religion





Religious beliefs shape how the world is viewed.
Is illness a punishment? The devil’s work? An
evil spell? Bad karma?
For Hispanics, the curandero is a trusted healer.
For Lakota Sioux, the ritual Vision Quest,
praying and fasting at a holy site is life
changing.

Remember there are as many
differences
Between individuals in the same
culture as there are between
individuals in different cultures!

Two African American
families, one lesbian
and the other, multi-racial.

German Consumers
Suggestions from our Gillespie County MH staff

What generation German?
 Would they feel more comfortable
speaking in German?


A consumer reacting to internal stimuli.

German Consumers
Suggestions from our Gillespie MHC staff in Fredericksburg

They may be resistant to seeking
mental services.
They may be reluctant to take medication.
They may “keep things within the family.”
They are concerned about the stigma.

German Consumers
They may feel it’s a character flaw or a
disgrace.
 They are very concerned about
confidentiality.
 Drinking alcohol is an accepted part of
their culture.
 Teen drinking may be acceptable in their
family.


Hispanic Consumers
from the U.S. Census, 1/23/03 Houston Chronicle

Hispanics are the largest minority group in
the U.S. with 37 million people.
 Texas is approximately 32 percent
Hispanic
 11.5 % African American,
 3.3% Other
 53.1% Anglo


Treatment Issues for Hispanic
Consumers
Do we need an interpreter?
 Is the person Tejano or from Mexico?
What generation Hispanic?
Is the person using a curandero?

Treatment issues for Hispanic
Consumers
Hallucinations are natural in their
religion.
 Hearing the voice of a loved one or having
hallucinations might be an expectations
when celebrating the Day of the Dead.
 Hispanic families are patriarchal.


Hispanic Consumers and
The Day of the Dead
A man is dressed in a skeleton
costume to portray death
in a celebration of
Dia de los Muertos,
The Day of the Dead.
People visit the graves of their
dead relatives to honor them.

Native Americans

Treatment Issues for Native
American Consumers
 Impact of racism,unemployment,and poverty.
 Coping with reservation life and
assimilation in mainstream culture.
 Consider the obesity, diabetes,
hypertension, and alcoholism in adults
and fetal alcohol syndrome in children.
 High use of native healers in the Southwest.

African Americans

African Americans
from the Houston Chronicle, 1/23/03

There are 36.2 million Americans who
identify themselves as “black only.”
 37.7 million identify themselves as “black
and at least one other race.”
 11.5% of Texans are African Americans.


Treatment Issues for African
American
Assess for co-occurring substance use
disorders and alcoholism.
 Address complications of obesity,
hypertension, diabetes,congestive heart
failure, asthma, and cancer.
 Sickle cell anemia is another illness
specific to African Americans.


Treatment Issues for African
Americans
Matriarchy; Mom or grandmother are the
dominant family figures.
 Lack of male role models and intact
families.
 Extended family or the Church may be
supports.


Treatment Issues for African
Americans


There is discrimination within their own
group based on skin color, hair texture,
class, values, etc.

Treatment Issues for Asians

Asians rarely seek help until its very severe.
Asians have extremely low admissions to state hospitals.
Mental illness is considered shameful. It’s hidden.
Is an interpreter needed?

Treatment Issues for Asians
Focus on physical symptoms.
 Asians are sensitive to medication.
 Give ½ the standard dose.
 Asians may use traditional healers and
herbal medicine.
 Asians may “flush” when drinking
alcohol.


Asian Consumers

Acupuncture has been used to treat
pain, schizophrenia, depression, and addictions.

Treatment Issues for Asians
Asian Cultures are patriarchal.
 The males in the family have the authority.
 Asians are more formal and inhibited in
their social behavior.


Older Adults

Treatment Issues for Older
Adults
Are they aware they need help?

Treatment Issues for Older
Adults
Is their mental illness caused by medicine?
 Do their medical problems cause or
complicate their mental illness?
 Is there Elder Abuse?


Gay Men and Lesbian Women
May struggle with homophobia and“being in the
closet” at work and with their families.
Gay people may want marriage, children, partner
benefits, etc., but may endure legal barriers.

Gay and Lesbian Women
Gay people often have specific health
issues related to their sexual practices.
 HIV, AIDS and STD’s are still concerns
with Gay men.
 People may be grieving the death of a
partner or friends who’ve died from AIDS,
or coping with living with AIDS or being
HIV+ themselves.


Treatment Issues for Gay and
Lesbians
Explore childhood abuse issues and
Domestic Violence..
 Assess for substance use and alcoholism.
 Sex enhancing drug use may be common
among some gay men.


Physically Challenged
Can they get to treatment?
Deal with their frustration and depression
Re: their disability.
 Do they need vocational assistance?

Mentally Challenged

Treatment Issues of Mentally
Challenged
They need to have meaningful activity
and purpose in their lives.
 They need to feel acknowledged and
appreciated.
 They need safety, structure, and security.
 Lack of continuity can cause crisis!
 They may need vocational assistance.


Winona Ryder

December 12, 2001,
Winona Ryder shoplifted
$5,560.40 designer items
from Saks Fifth Avenue in
Beverley Hills.

Twice an Academy
Award Nominated
actress

She had the following 8 drugs in
her possession:
Liquid demerol
 Liquid Diazepam
 Vicodin
 Percodan
 Valium
 Morphine sulfate
 Endocet (containing Oxycodone)


Patterns of Drug Use are highly
Regional.
 Drugs,

routes of administration, street
names, patterns of use, and drug
combinations may differ greatly, not
only between individuals from
different cultures, but different parts
of the country or even different parts
of the city.

Drugs of Choice
Native Americans-alcohol
 Asians-gambling, work
 Gay Men-stimulants, amyl nitrate, ecstasy
 “Rich”-prescription drugs, Internet porn
 M.D.’s –Vicodin


Drugs of Choice
Young adults-marijuana, cigarettes
 Geriatrics-alcohol, pills
 Sex Workers-crack cocaine, IV speedballs
 Screen mentally retarded for abuse too!


How Do We Best Serve Our
Consumers?




Examine own stereotypes.
Build trust.
Use People First language!

How do we best serve our
consumers?
Pronounce the person’s name correctly.
 Get an interpreter, if necessary.
 Educate yourself from the consumer, his
family, co-workers, etc.
 Remember differences do matter!



Slide 55

Cultural Competence
Integrating Differences
into Community Services

Objectives
Understand Stigma.
 Understand Culture Competency.
 Learn Culturally competent care for
people with Mental Health, Mental
Retardation and Addictions.


We live in an world
which often separates us.
Racism
 Sexism
 Ageism
 Feminism
 Classism
 Atheism


“Different” people are
“Stigmatized”

Mentally retarded inmates in a sanitorium in Germany

Stigma
Definitions from the U. of Chicago PSR Training Manual

“Stigmas are negative attitudes about a
group that lead to depriving them of
some fair opportunities.”

Stigma is related to…..
Stereotypes
Prejudice
Discrimination

Stereotypes
from The Asian Health Coalition of Illinois

Stereotypes are exaggerated beliefs
or fixed ideas about a person or
group which is held by people and
sustained by selective perception and
selective forgetting.

Prejudice
from The Asian Health Coalition of Illinois

Prejudice is a preconceived idea or
negative attitude formed before the
facts are known and sustained over
generalizations. A bias without
reason, resisting all evidence…

Discrimination
from The Asian Health Coalition of Illinois

Discrimination refers to treatment in
favor or against a person based on
the group to which that person
belongs and not on merit.

Stigmatized People…..
Experience being stereotyped and
are often the object of
discrimination and prejudice.

People are often stigmatized by:













Mental Illness
Mental Retardation
Physical Disability (including blindness, deafness)
Alcoholism /and or Drug Addiction
HIV or AIDS, Cancer or other terminal illnesses
Criminal behavior
Poverty
Alternative Lifestyles/sexual orientation
Wheelchair bound
Gender
Obesity

All our Consumers belong to
stigmatized groups!

Stigmatized People
Consumers and their families
can’t navigate the bureaucracy
even if resources are there.
It’s too frustrating!

Use People First Language
“I am more than my
illness….Don’t call me
“the schizophrenic,
“the addict” or
“the retard.”

As human beings, we have many
similarities…..
But, who we really are, is often
derived from our original family of origin
and our current lifestyle.

The Bottom Line:
People are different, even within
their own culture!
These differences matter when
planning and providing services.

National Mental Health
Association
“For Mental Health consumers, both
access to the services and the effectiveness
of the care they receive are greatly affected
by the degree to which the delivery system
is“culturally competent.”

Some important definitions
Related to Cultural Competency

Culture

from King,et. al

The Office of Special Programs, U.S. Dept. of Education

“The integrated patterns of human
behavior that includes thoughts,
communications, actions, customs,
beliefs,values, and institutions of
racial, ethnic, religious, or social
groups.”

Cultural Sensitivity
An awareness and respect of a
person’s cultural beliefs and
values.
Culhane-Pera, et .al

Cultural Competency
 Skills

(that translate into)
 Behaviors, Practices, Attitudes, and
 Policies
That enable an individual, agency, or
system to effectively serve culturally
diverse communities.
from The Asian Health Coalition of Illinois

Here at Hill Country MHDDC
Consumers are very diverse in their
language and culture.

61% of our Consumers are
Caucasian Americans
Many have German
backgrounds.

Our Consumers are …..

n
1% NativeAmerican

33% Hispanic
1% Asian

3% African
American

1% are “Others”

Consumers Have Many
Different Lifestyles

Lifestyles

They have many different
beliefs.

Can We Communicate?
Think Language first!
 Do we need an interpreter?
 Communicate respectfully.
 Be sensitive to the consumer and the family.
 Consider your dress, tone of voice, eye contact,
location, seating arrangement, privacy, etc.


Is our approach culturally
appropriate?
“What do you call your problem?”
“What name does it have?”
“What do you think caused your problem?”
“Why do you think it started when it did?”
From Arthur Kleinman’s question protocol in“Culture,Illness, and Care:
Clinical Lessons from Anthropologic and Cross Cultural Research”,
Ann.Intern.Med. 1978:Vol.88, pg.251-258

Important Issues to Consider…





Impact of religion.
How are women, men, elders, and children
treated in their culture?
Is there domestic violence?
Ethnic minorities generally underutilize
outpatient services, although African-Americans
are over-represented in inpatient setting.

Diagnosis






Minorities with Bipolar Disorder are often
diagnosed with schizophrenia. (Mukherjee,et al)
African Americans are over diagnosed with
schizophrenia and under diagnosed with mood
disorders. (Bell )
A mental health consumer’s addictions may not
be treated.
The elderly may not be assessed for substance
abuse or alcoholism.

Diagnosis
A person with a primary addiction problem
might not be treated for a co-occurring mental
illness.
 Learning disabilities may not be identified in
individuals with mental illness or substance
abuse.
 A person with mental retardation may not be
treated for mental illness or substance abuse.


Diagnosis
Post Traumatic Stress Disorder is often
undiagnosed in people suffering from
Domestic Abuse or other trauma.
 Children who are witnessing or are
victims of domestic abuse or another
trauma, may be misdiagnosed with
Attention Deficit Hyperactivity Disorder.


Medication Differences





Asians and Hispanics need lower doses of antipsychotics.
African Americans use the same doses of antipsychotics, but lower doses of lithium.
The elderly need lower dosages of medications.
Thus, metabolism of drugs varies with age and
ethnicity and is critical in prescribing
medications.

From “Making Room for Culture in Psychiatry” by Lin, et al.

Pain Tolerance
Men and women tolerate pain differently.
 Cultures tolerate pain differently.
 People with addictions develop a
hypersensitivity to pain.
 In certain cultures, self-inflicted pain is a
part of a religious experience.


Religion





Religious beliefs shape how the world is viewed.
Is illness a punishment? The devil’s work? An
evil spell? Bad karma?
For Hispanics, the curandero is a trusted healer.
For Lakota Sioux, the ritual Vision Quest,
praying and fasting at a holy site is life
changing.

Remember there are as many
differences
Between individuals in the same
culture as there are between
individuals in different cultures!

Two African American
families, one lesbian
and the other, multi-racial.

German Consumers
Suggestions from our Gillespie County MH staff

What generation German?
 Would they feel more comfortable
speaking in German?


A consumer reacting to internal stimuli.

German Consumers
Suggestions from our Gillespie MHC staff in Fredericksburg

They may be resistant to seeking
mental services.
They may be reluctant to take medication.
They may “keep things within the family.”
They are concerned about the stigma.

German Consumers
They may feel it’s a character flaw or a
disgrace.
 They are very concerned about
confidentiality.
 Drinking alcohol is an accepted part of
their culture.
 Teen drinking may be acceptable in their
family.


Hispanic Consumers
from the U.S. Census, 1/23/03 Houston Chronicle

Hispanics are the largest minority group in
the U.S. with 37 million people.
 Texas is approximately 32 percent
Hispanic
 11.5 % African American,
 3.3% Other
 53.1% Anglo


Treatment Issues for Hispanic
Consumers
Do we need an interpreter?
 Is the person Tejano or from Mexico?
What generation Hispanic?
Is the person using a curandero?

Treatment issues for Hispanic
Consumers
Hallucinations are natural in their
religion.
 Hearing the voice of a loved one or having
hallucinations might be an expectations
when celebrating the Day of the Dead.
 Hispanic families are patriarchal.


Hispanic Consumers and
The Day of the Dead
A man is dressed in a skeleton
costume to portray death
in a celebration of
Dia de los Muertos,
The Day of the Dead.
People visit the graves of their
dead relatives to honor them.

Native Americans

Treatment Issues for Native
American Consumers
 Impact of racism,unemployment,and poverty.
 Coping with reservation life and
assimilation in mainstream culture.
 Consider the obesity, diabetes,
hypertension, and alcoholism in adults
and fetal alcohol syndrome in children.
 High use of native healers in the Southwest.

African Americans

African Americans
from the Houston Chronicle, 1/23/03

There are 36.2 million Americans who
identify themselves as “black only.”
 37.7 million identify themselves as “black
and at least one other race.”
 11.5% of Texans are African Americans.


Treatment Issues for African
American
Assess for co-occurring substance use
disorders and alcoholism.
 Address complications of obesity,
hypertension, diabetes,congestive heart
failure, asthma, and cancer.
 Sickle cell anemia is another illness
specific to African Americans.


Treatment Issues for African
Americans
Matriarchy; Mom or grandmother are the
dominant family figures.
 Lack of male role models and intact
families.
 Extended family or the Church may be
supports.


Treatment Issues for African
Americans


There is discrimination within their own
group based on skin color, hair texture,
class, values, etc.

Treatment Issues for Asians

Asians rarely seek help until its very severe.
Asians have extremely low admissions to state hospitals.
Mental illness is considered shameful. It’s hidden.
Is an interpreter needed?

Treatment Issues for Asians
Focus on physical symptoms.
 Asians are sensitive to medication.
 Give ½ the standard dose.
 Asians may use traditional healers and
herbal medicine.
 Asians may “flush” when drinking
alcohol.


Asian Consumers

Acupuncture has been used to treat
pain, schizophrenia, depression, and addictions.

Treatment Issues for Asians
Asian Cultures are patriarchal.
 The males in the family have the authority.
 Asians are more formal and inhibited in
their social behavior.


Older Adults

Treatment Issues for Older
Adults
Are they aware they need help?

Treatment Issues for Older
Adults
Is their mental illness caused by medicine?
 Do their medical problems cause or
complicate their mental illness?
 Is there Elder Abuse?


Gay Men and Lesbian Women
May struggle with homophobia and“being in the
closet” at work and with their families.
Gay people may want marriage, children, partner
benefits, etc., but may endure legal barriers.

Gay and Lesbian Women
Gay people often have specific health
issues related to their sexual practices.
 HIV, AIDS and STD’s are still concerns
with Gay men.
 People may be grieving the death of a
partner or friends who’ve died from AIDS,
or coping with living with AIDS or being
HIV+ themselves.


Treatment Issues for Gay and
Lesbians
Explore childhood abuse issues and
Domestic Violence..
 Assess for substance use and alcoholism.
 Sex enhancing drug use may be common
among some gay men.


Physically Challenged
Can they get to treatment?
Deal with their frustration and depression
Re: their disability.
 Do they need vocational assistance?

Mentally Challenged

Treatment Issues of Mentally
Challenged
They need to have meaningful activity
and purpose in their lives.
 They need to feel acknowledged and
appreciated.
 They need safety, structure, and security.
 Lack of continuity can cause crisis!
 They may need vocational assistance.


Winona Ryder

December 12, 2001,
Winona Ryder shoplifted
$5,560.40 designer items
from Saks Fifth Avenue in
Beverley Hills.

Twice an Academy
Award Nominated
actress

She had the following 8 drugs in
her possession:
Liquid demerol
 Liquid Diazepam
 Vicodin
 Percodan
 Valium
 Morphine sulfate
 Endocet (containing Oxycodone)


Patterns of Drug Use are highly
Regional.
 Drugs,

routes of administration, street
names, patterns of use, and drug
combinations may differ greatly, not
only between individuals from
different cultures, but different parts
of the country or even different parts
of the city.

Drugs of Choice
Native Americans-alcohol
 Asians-gambling, work
 Gay Men-stimulants, amyl nitrate, ecstasy
 “Rich”-prescription drugs, Internet porn
 M.D.’s –Vicodin


Drugs of Choice
Young adults-marijuana, cigarettes
 Geriatrics-alcohol, pills
 Sex Workers-crack cocaine, IV speedballs
 Screen mentally retarded for abuse too!


How Do We Best Serve Our
Consumers?




Examine own stereotypes.
Build trust.
Use People First language!

How do we best serve our
consumers?
Pronounce the person’s name correctly.
 Get an interpreter, if necessary.
 Educate yourself from the consumer, his
family, co-workers, etc.
 Remember differences do matter!



Slide 56

Cultural Competence
Integrating Differences
into Community Services

Objectives
Understand Stigma.
 Understand Culture Competency.
 Learn Culturally competent care for
people with Mental Health, Mental
Retardation and Addictions.


We live in an world
which often separates us.
Racism
 Sexism
 Ageism
 Feminism
 Classism
 Atheism


“Different” people are
“Stigmatized”

Mentally retarded inmates in a sanitorium in Germany

Stigma
Definitions from the U. of Chicago PSR Training Manual

“Stigmas are negative attitudes about a
group that lead to depriving them of
some fair opportunities.”

Stigma is related to…..
Stereotypes
Prejudice
Discrimination

Stereotypes
from The Asian Health Coalition of Illinois

Stereotypes are exaggerated beliefs
or fixed ideas about a person or
group which is held by people and
sustained by selective perception and
selective forgetting.

Prejudice
from The Asian Health Coalition of Illinois

Prejudice is a preconceived idea or
negative attitude formed before the
facts are known and sustained over
generalizations. A bias without
reason, resisting all evidence…

Discrimination
from The Asian Health Coalition of Illinois

Discrimination refers to treatment in
favor or against a person based on
the group to which that person
belongs and not on merit.

Stigmatized People…..
Experience being stereotyped and
are often the object of
discrimination and prejudice.

People are often stigmatized by:













Mental Illness
Mental Retardation
Physical Disability (including blindness, deafness)
Alcoholism /and or Drug Addiction
HIV or AIDS, Cancer or other terminal illnesses
Criminal behavior
Poverty
Alternative Lifestyles/sexual orientation
Wheelchair bound
Gender
Obesity

All our Consumers belong to
stigmatized groups!

Stigmatized People
Consumers and their families
can’t navigate the bureaucracy
even if resources are there.
It’s too frustrating!

Use People First Language
“I am more than my
illness….Don’t call me
“the schizophrenic,
“the addict” or
“the retard.”

As human beings, we have many
similarities…..
But, who we really are, is often
derived from our original family of origin
and our current lifestyle.

The Bottom Line:
People are different, even within
their own culture!
These differences matter when
planning and providing services.

National Mental Health
Association
“For Mental Health consumers, both
access to the services and the effectiveness
of the care they receive are greatly affected
by the degree to which the delivery system
is“culturally competent.”

Some important definitions
Related to Cultural Competency

Culture

from King,et. al

The Office of Special Programs, U.S. Dept. of Education

“The integrated patterns of human
behavior that includes thoughts,
communications, actions, customs,
beliefs,values, and institutions of
racial, ethnic, religious, or social
groups.”

Cultural Sensitivity
An awareness and respect of a
person’s cultural beliefs and
values.
Culhane-Pera, et .al

Cultural Competency
 Skills

(that translate into)
 Behaviors, Practices, Attitudes, and
 Policies
That enable an individual, agency, or
system to effectively serve culturally
diverse communities.
from The Asian Health Coalition of Illinois

Here at Hill Country MHDDC
Consumers are very diverse in their
language and culture.

61% of our Consumers are
Caucasian Americans
Many have German
backgrounds.

Our Consumers are …..

n
1% NativeAmerican

33% Hispanic
1% Asian

3% African
American

1% are “Others”

Consumers Have Many
Different Lifestyles

Lifestyles

They have many different
beliefs.

Can We Communicate?
Think Language first!
 Do we need an interpreter?
 Communicate respectfully.
 Be sensitive to the consumer and the family.
 Consider your dress, tone of voice, eye contact,
location, seating arrangement, privacy, etc.


Is our approach culturally
appropriate?
“What do you call your problem?”
“What name does it have?”
“What do you think caused your problem?”
“Why do you think it started when it did?”
From Arthur Kleinman’s question protocol in“Culture,Illness, and Care:
Clinical Lessons from Anthropologic and Cross Cultural Research”,
Ann.Intern.Med. 1978:Vol.88, pg.251-258

Important Issues to Consider…





Impact of religion.
How are women, men, elders, and children
treated in their culture?
Is there domestic violence?
Ethnic minorities generally underutilize
outpatient services, although African-Americans
are over-represented in inpatient setting.

Diagnosis






Minorities with Bipolar Disorder are often
diagnosed with schizophrenia. (Mukherjee,et al)
African Americans are over diagnosed with
schizophrenia and under diagnosed with mood
disorders. (Bell )
A mental health consumer’s addictions may not
be treated.
The elderly may not be assessed for substance
abuse or alcoholism.

Diagnosis
A person with a primary addiction problem
might not be treated for a co-occurring mental
illness.
 Learning disabilities may not be identified in
individuals with mental illness or substance
abuse.
 A person with mental retardation may not be
treated for mental illness or substance abuse.


Diagnosis
Post Traumatic Stress Disorder is often
undiagnosed in people suffering from
Domestic Abuse or other trauma.
 Children who are witnessing or are
victims of domestic abuse or another
trauma, may be misdiagnosed with
Attention Deficit Hyperactivity Disorder.


Medication Differences





Asians and Hispanics need lower doses of antipsychotics.
African Americans use the same doses of antipsychotics, but lower doses of lithium.
The elderly need lower dosages of medications.
Thus, metabolism of drugs varies with age and
ethnicity and is critical in prescribing
medications.

From “Making Room for Culture in Psychiatry” by Lin, et al.

Pain Tolerance
Men and women tolerate pain differently.
 Cultures tolerate pain differently.
 People with addictions develop a
hypersensitivity to pain.
 In certain cultures, self-inflicted pain is a
part of a religious experience.


Religion





Religious beliefs shape how the world is viewed.
Is illness a punishment? The devil’s work? An
evil spell? Bad karma?
For Hispanics, the curandero is a trusted healer.
For Lakota Sioux, the ritual Vision Quest,
praying and fasting at a holy site is life
changing.

Remember there are as many
differences
Between individuals in the same
culture as there are between
individuals in different cultures!

Two African American
families, one lesbian
and the other, multi-racial.

German Consumers
Suggestions from our Gillespie County MH staff

What generation German?
 Would they feel more comfortable
speaking in German?


A consumer reacting to internal stimuli.

German Consumers
Suggestions from our Gillespie MHC staff in Fredericksburg

They may be resistant to seeking
mental services.
They may be reluctant to take medication.
They may “keep things within the family.”
They are concerned about the stigma.

German Consumers
They may feel it’s a character flaw or a
disgrace.
 They are very concerned about
confidentiality.
 Drinking alcohol is an accepted part of
their culture.
 Teen drinking may be acceptable in their
family.


Hispanic Consumers
from the U.S. Census, 1/23/03 Houston Chronicle

Hispanics are the largest minority group in
the U.S. with 37 million people.
 Texas is approximately 32 percent
Hispanic
 11.5 % African American,
 3.3% Other
 53.1% Anglo


Treatment Issues for Hispanic
Consumers
Do we need an interpreter?
 Is the person Tejano or from Mexico?
What generation Hispanic?
Is the person using a curandero?

Treatment issues for Hispanic
Consumers
Hallucinations are natural in their
religion.
 Hearing the voice of a loved one or having
hallucinations might be an expectations
when celebrating the Day of the Dead.
 Hispanic families are patriarchal.


Hispanic Consumers and
The Day of the Dead
A man is dressed in a skeleton
costume to portray death
in a celebration of
Dia de los Muertos,
The Day of the Dead.
People visit the graves of their
dead relatives to honor them.

Native Americans

Treatment Issues for Native
American Consumers
 Impact of racism,unemployment,and poverty.
 Coping with reservation life and
assimilation in mainstream culture.
 Consider the obesity, diabetes,
hypertension, and alcoholism in adults
and fetal alcohol syndrome in children.
 High use of native healers in the Southwest.

African Americans

African Americans
from the Houston Chronicle, 1/23/03

There are 36.2 million Americans who
identify themselves as “black only.”
 37.7 million identify themselves as “black
and at least one other race.”
 11.5% of Texans are African Americans.


Treatment Issues for African
American
Assess for co-occurring substance use
disorders and alcoholism.
 Address complications of obesity,
hypertension, diabetes,congestive heart
failure, asthma, and cancer.
 Sickle cell anemia is another illness
specific to African Americans.


Treatment Issues for African
Americans
Matriarchy; Mom or grandmother are the
dominant family figures.
 Lack of male role models and intact
families.
 Extended family or the Church may be
supports.


Treatment Issues for African
Americans


There is discrimination within their own
group based on skin color, hair texture,
class, values, etc.

Treatment Issues for Asians

Asians rarely seek help until its very severe.
Asians have extremely low admissions to state hospitals.
Mental illness is considered shameful. It’s hidden.
Is an interpreter needed?

Treatment Issues for Asians
Focus on physical symptoms.
 Asians are sensitive to medication.
 Give ½ the standard dose.
 Asians may use traditional healers and
herbal medicine.
 Asians may “flush” when drinking
alcohol.


Asian Consumers

Acupuncture has been used to treat
pain, schizophrenia, depression, and addictions.

Treatment Issues for Asians
Asian Cultures are patriarchal.
 The males in the family have the authority.
 Asians are more formal and inhibited in
their social behavior.


Older Adults

Treatment Issues for Older
Adults
Are they aware they need help?

Treatment Issues for Older
Adults
Is their mental illness caused by medicine?
 Do their medical problems cause or
complicate their mental illness?
 Is there Elder Abuse?


Gay Men and Lesbian Women
May struggle with homophobia and“being in the
closet” at work and with their families.
Gay people may want marriage, children, partner
benefits, etc., but may endure legal barriers.

Gay and Lesbian Women
Gay people often have specific health
issues related to their sexual practices.
 HIV, AIDS and STD’s are still concerns
with Gay men.
 People may be grieving the death of a
partner or friends who’ve died from AIDS,
or coping with living with AIDS or being
HIV+ themselves.


Treatment Issues for Gay and
Lesbians
Explore childhood abuse issues and
Domestic Violence..
 Assess for substance use and alcoholism.
 Sex enhancing drug use may be common
among some gay men.


Physically Challenged
Can they get to treatment?
Deal with their frustration and depression
Re: their disability.
 Do they need vocational assistance?

Mentally Challenged

Treatment Issues of Mentally
Challenged
They need to have meaningful activity
and purpose in their lives.
 They need to feel acknowledged and
appreciated.
 They need safety, structure, and security.
 Lack of continuity can cause crisis!
 They may need vocational assistance.


Winona Ryder

December 12, 2001,
Winona Ryder shoplifted
$5,560.40 designer items
from Saks Fifth Avenue in
Beverley Hills.

Twice an Academy
Award Nominated
actress

She had the following 8 drugs in
her possession:
Liquid demerol
 Liquid Diazepam
 Vicodin
 Percodan
 Valium
 Morphine sulfate
 Endocet (containing Oxycodone)


Patterns of Drug Use are highly
Regional.
 Drugs,

routes of administration, street
names, patterns of use, and drug
combinations may differ greatly, not
only between individuals from
different cultures, but different parts
of the country or even different parts
of the city.

Drugs of Choice
Native Americans-alcohol
 Asians-gambling, work
 Gay Men-stimulants, amyl nitrate, ecstasy
 “Rich”-prescription drugs, Internet porn
 M.D.’s –Vicodin


Drugs of Choice
Young adults-marijuana, cigarettes
 Geriatrics-alcohol, pills
 Sex Workers-crack cocaine, IV speedballs
 Screen mentally retarded for abuse too!


How Do We Best Serve Our
Consumers?




Examine own stereotypes.
Build trust.
Use People First language!

How do we best serve our
consumers?
Pronounce the person’s name correctly.
 Get an interpreter, if necessary.
 Educate yourself from the consumer, his
family, co-workers, etc.
 Remember differences do matter!



Slide 57

Cultural Competence
Integrating Differences
into Community Services

Objectives
Understand Stigma.
 Understand Culture Competency.
 Learn Culturally competent care for
people with Mental Health, Mental
Retardation and Addictions.


We live in an world
which often separates us.
Racism
 Sexism
 Ageism
 Feminism
 Classism
 Atheism


“Different” people are
“Stigmatized”

Mentally retarded inmates in a sanitorium in Germany

Stigma
Definitions from the U. of Chicago PSR Training Manual

“Stigmas are negative attitudes about a
group that lead to depriving them of
some fair opportunities.”

Stigma is related to…..
Stereotypes
Prejudice
Discrimination

Stereotypes
from The Asian Health Coalition of Illinois

Stereotypes are exaggerated beliefs
or fixed ideas about a person or
group which is held by people and
sustained by selective perception and
selective forgetting.

Prejudice
from The Asian Health Coalition of Illinois

Prejudice is a preconceived idea or
negative attitude formed before the
facts are known and sustained over
generalizations. A bias without
reason, resisting all evidence…

Discrimination
from The Asian Health Coalition of Illinois

Discrimination refers to treatment in
favor or against a person based on
the group to which that person
belongs and not on merit.

Stigmatized People…..
Experience being stereotyped and
are often the object of
discrimination and prejudice.

People are often stigmatized by:













Mental Illness
Mental Retardation
Physical Disability (including blindness, deafness)
Alcoholism /and or Drug Addiction
HIV or AIDS, Cancer or other terminal illnesses
Criminal behavior
Poverty
Alternative Lifestyles/sexual orientation
Wheelchair bound
Gender
Obesity

All our Consumers belong to
stigmatized groups!

Stigmatized People
Consumers and their families
can’t navigate the bureaucracy
even if resources are there.
It’s too frustrating!

Use People First Language
“I am more than my
illness….Don’t call me
“the schizophrenic,
“the addict” or
“the retard.”

As human beings, we have many
similarities…..
But, who we really are, is often
derived from our original family of origin
and our current lifestyle.

The Bottom Line:
People are different, even within
their own culture!
These differences matter when
planning and providing services.

National Mental Health
Association
“For Mental Health consumers, both
access to the services and the effectiveness
of the care they receive are greatly affected
by the degree to which the delivery system
is“culturally competent.”

Some important definitions
Related to Cultural Competency

Culture

from King,et. al

The Office of Special Programs, U.S. Dept. of Education

“The integrated patterns of human
behavior that includes thoughts,
communications, actions, customs,
beliefs,values, and institutions of
racial, ethnic, religious, or social
groups.”

Cultural Sensitivity
An awareness and respect of a
person’s cultural beliefs and
values.
Culhane-Pera, et .al

Cultural Competency
 Skills

(that translate into)
 Behaviors, Practices, Attitudes, and
 Policies
That enable an individual, agency, or
system to effectively serve culturally
diverse communities.
from The Asian Health Coalition of Illinois

Here at Hill Country MHDDC
Consumers are very diverse in their
language and culture.

61% of our Consumers are
Caucasian Americans
Many have German
backgrounds.

Our Consumers are …..

n
1% NativeAmerican

33% Hispanic
1% Asian

3% African
American

1% are “Others”

Consumers Have Many
Different Lifestyles

Lifestyles

They have many different
beliefs.

Can We Communicate?
Think Language first!
 Do we need an interpreter?
 Communicate respectfully.
 Be sensitive to the consumer and the family.
 Consider your dress, tone of voice, eye contact,
location, seating arrangement, privacy, etc.


Is our approach culturally
appropriate?
“What do you call your problem?”
“What name does it have?”
“What do you think caused your problem?”
“Why do you think it started when it did?”
From Arthur Kleinman’s question protocol in“Culture,Illness, and Care:
Clinical Lessons from Anthropologic and Cross Cultural Research”,
Ann.Intern.Med. 1978:Vol.88, pg.251-258

Important Issues to Consider…





Impact of religion.
How are women, men, elders, and children
treated in their culture?
Is there domestic violence?
Ethnic minorities generally underutilize
outpatient services, although African-Americans
are over-represented in inpatient setting.

Diagnosis






Minorities with Bipolar Disorder are often
diagnosed with schizophrenia. (Mukherjee,et al)
African Americans are over diagnosed with
schizophrenia and under diagnosed with mood
disorders. (Bell )
A mental health consumer’s addictions may not
be treated.
The elderly may not be assessed for substance
abuse or alcoholism.

Diagnosis
A person with a primary addiction problem
might not be treated for a co-occurring mental
illness.
 Learning disabilities may not be identified in
individuals with mental illness or substance
abuse.
 A person with mental retardation may not be
treated for mental illness or substance abuse.


Diagnosis
Post Traumatic Stress Disorder is often
undiagnosed in people suffering from
Domestic Abuse or other trauma.
 Children who are witnessing or are
victims of domestic abuse or another
trauma, may be misdiagnosed with
Attention Deficit Hyperactivity Disorder.


Medication Differences





Asians and Hispanics need lower doses of antipsychotics.
African Americans use the same doses of antipsychotics, but lower doses of lithium.
The elderly need lower dosages of medications.
Thus, metabolism of drugs varies with age and
ethnicity and is critical in prescribing
medications.

From “Making Room for Culture in Psychiatry” by Lin, et al.

Pain Tolerance
Men and women tolerate pain differently.
 Cultures tolerate pain differently.
 People with addictions develop a
hypersensitivity to pain.
 In certain cultures, self-inflicted pain is a
part of a religious experience.


Religion





Religious beliefs shape how the world is viewed.
Is illness a punishment? The devil’s work? An
evil spell? Bad karma?
For Hispanics, the curandero is a trusted healer.
For Lakota Sioux, the ritual Vision Quest,
praying and fasting at a holy site is life
changing.

Remember there are as many
differences
Between individuals in the same
culture as there are between
individuals in different cultures!

Two African American
families, one lesbian
and the other, multi-racial.

German Consumers
Suggestions from our Gillespie County MH staff

What generation German?
 Would they feel more comfortable
speaking in German?


A consumer reacting to internal stimuli.

German Consumers
Suggestions from our Gillespie MHC staff in Fredericksburg

They may be resistant to seeking
mental services.
They may be reluctant to take medication.
They may “keep things within the family.”
They are concerned about the stigma.

German Consumers
They may feel it’s a character flaw or a
disgrace.
 They are very concerned about
confidentiality.
 Drinking alcohol is an accepted part of
their culture.
 Teen drinking may be acceptable in their
family.


Hispanic Consumers
from the U.S. Census, 1/23/03 Houston Chronicle

Hispanics are the largest minority group in
the U.S. with 37 million people.
 Texas is approximately 32 percent
Hispanic
 11.5 % African American,
 3.3% Other
 53.1% Anglo


Treatment Issues for Hispanic
Consumers
Do we need an interpreter?
 Is the person Tejano or from Mexico?
What generation Hispanic?
Is the person using a curandero?

Treatment issues for Hispanic
Consumers
Hallucinations are natural in their
religion.
 Hearing the voice of a loved one or having
hallucinations might be an expectations
when celebrating the Day of the Dead.
 Hispanic families are patriarchal.


Hispanic Consumers and
The Day of the Dead
A man is dressed in a skeleton
costume to portray death
in a celebration of
Dia de los Muertos,
The Day of the Dead.
People visit the graves of their
dead relatives to honor them.

Native Americans

Treatment Issues for Native
American Consumers
 Impact of racism,unemployment,and poverty.
 Coping with reservation life and
assimilation in mainstream culture.
 Consider the obesity, diabetes,
hypertension, and alcoholism in adults
and fetal alcohol syndrome in children.
 High use of native healers in the Southwest.

African Americans

African Americans
from the Houston Chronicle, 1/23/03

There are 36.2 million Americans who
identify themselves as “black only.”
 37.7 million identify themselves as “black
and at least one other race.”
 11.5% of Texans are African Americans.


Treatment Issues for African
American
Assess for co-occurring substance use
disorders and alcoholism.
 Address complications of obesity,
hypertension, diabetes,congestive heart
failure, asthma, and cancer.
 Sickle cell anemia is another illness
specific to African Americans.


Treatment Issues for African
Americans
Matriarchy; Mom or grandmother are the
dominant family figures.
 Lack of male role models and intact
families.
 Extended family or the Church may be
supports.


Treatment Issues for African
Americans


There is discrimination within their own
group based on skin color, hair texture,
class, values, etc.

Treatment Issues for Asians

Asians rarely seek help until its very severe.
Asians have extremely low admissions to state hospitals.
Mental illness is considered shameful. It’s hidden.
Is an interpreter needed?

Treatment Issues for Asians
Focus on physical symptoms.
 Asians are sensitive to medication.
 Give ½ the standard dose.
 Asians may use traditional healers and
herbal medicine.
 Asians may “flush” when drinking
alcohol.


Asian Consumers

Acupuncture has been used to treat
pain, schizophrenia, depression, and addictions.

Treatment Issues for Asians
Asian Cultures are patriarchal.
 The males in the family have the authority.
 Asians are more formal and inhibited in
their social behavior.


Older Adults

Treatment Issues for Older
Adults
Are they aware they need help?

Treatment Issues for Older
Adults
Is their mental illness caused by medicine?
 Do their medical problems cause or
complicate their mental illness?
 Is there Elder Abuse?


Gay Men and Lesbian Women
May struggle with homophobia and“being in the
closet” at work and with their families.
Gay people may want marriage, children, partner
benefits, etc., but may endure legal barriers.

Gay and Lesbian Women
Gay people often have specific health
issues related to their sexual practices.
 HIV, AIDS and STD’s are still concerns
with Gay men.
 People may be grieving the death of a
partner or friends who’ve died from AIDS,
or coping with living with AIDS or being
HIV+ themselves.


Treatment Issues for Gay and
Lesbians
Explore childhood abuse issues and
Domestic Violence..
 Assess for substance use and alcoholism.
 Sex enhancing drug use may be common
among some gay men.


Physically Challenged
Can they get to treatment?
Deal with their frustration and depression
Re: their disability.
 Do they need vocational assistance?

Mentally Challenged

Treatment Issues of Mentally
Challenged
They need to have meaningful activity
and purpose in their lives.
 They need to feel acknowledged and
appreciated.
 They need safety, structure, and security.
 Lack of continuity can cause crisis!
 They may need vocational assistance.


Winona Ryder

December 12, 2001,
Winona Ryder shoplifted
$5,560.40 designer items
from Saks Fifth Avenue in
Beverley Hills.

Twice an Academy
Award Nominated
actress

She had the following 8 drugs in
her possession:
Liquid demerol
 Liquid Diazepam
 Vicodin
 Percodan
 Valium
 Morphine sulfate
 Endocet (containing Oxycodone)


Patterns of Drug Use are highly
Regional.
 Drugs,

routes of administration, street
names, patterns of use, and drug
combinations may differ greatly, not
only between individuals from
different cultures, but different parts
of the country or even different parts
of the city.

Drugs of Choice
Native Americans-alcohol
 Asians-gambling, work
 Gay Men-stimulants, amyl nitrate, ecstasy
 “Rich”-prescription drugs, Internet porn
 M.D.’s –Vicodin


Drugs of Choice
Young adults-marijuana, cigarettes
 Geriatrics-alcohol, pills
 Sex Workers-crack cocaine, IV speedballs
 Screen mentally retarded for abuse too!


How Do We Best Serve Our
Consumers?




Examine own stereotypes.
Build trust.
Use People First language!

How do we best serve our
consumers?
Pronounce the person’s name correctly.
 Get an interpreter, if necessary.
 Educate yourself from the consumer, his
family, co-workers, etc.
 Remember differences do matter!



Slide 58

Cultural Competence
Integrating Differences
into Community Services

Objectives
Understand Stigma.
 Understand Culture Competency.
 Learn Culturally competent care for
people with Mental Health, Mental
Retardation and Addictions.


We live in an world
which often separates us.
Racism
 Sexism
 Ageism
 Feminism
 Classism
 Atheism


“Different” people are
“Stigmatized”

Mentally retarded inmates in a sanitorium in Germany

Stigma
Definitions from the U. of Chicago PSR Training Manual

“Stigmas are negative attitudes about a
group that lead to depriving them of
some fair opportunities.”

Stigma is related to…..
Stereotypes
Prejudice
Discrimination

Stereotypes
from The Asian Health Coalition of Illinois

Stereotypes are exaggerated beliefs
or fixed ideas about a person or
group which is held by people and
sustained by selective perception and
selective forgetting.

Prejudice
from The Asian Health Coalition of Illinois

Prejudice is a preconceived idea or
negative attitude formed before the
facts are known and sustained over
generalizations. A bias without
reason, resisting all evidence…

Discrimination
from The Asian Health Coalition of Illinois

Discrimination refers to treatment in
favor or against a person based on
the group to which that person
belongs and not on merit.

Stigmatized People…..
Experience being stereotyped and
are often the object of
discrimination and prejudice.

People are often stigmatized by:













Mental Illness
Mental Retardation
Physical Disability (including blindness, deafness)
Alcoholism /and or Drug Addiction
HIV or AIDS, Cancer or other terminal illnesses
Criminal behavior
Poverty
Alternative Lifestyles/sexual orientation
Wheelchair bound
Gender
Obesity

All our Consumers belong to
stigmatized groups!

Stigmatized People
Consumers and their families
can’t navigate the bureaucracy
even if resources are there.
It’s too frustrating!

Use People First Language
“I am more than my
illness….Don’t call me
“the schizophrenic,
“the addict” or
“the retard.”

As human beings, we have many
similarities…..
But, who we really are, is often
derived from our original family of origin
and our current lifestyle.

The Bottom Line:
People are different, even within
their own culture!
These differences matter when
planning and providing services.

National Mental Health
Association
“For Mental Health consumers, both
access to the services and the effectiveness
of the care they receive are greatly affected
by the degree to which the delivery system
is“culturally competent.”

Some important definitions
Related to Cultural Competency

Culture

from King,et. al

The Office of Special Programs, U.S. Dept. of Education

“The integrated patterns of human
behavior that includes thoughts,
communications, actions, customs,
beliefs,values, and institutions of
racial, ethnic, religious, or social
groups.”

Cultural Sensitivity
An awareness and respect of a
person’s cultural beliefs and
values.
Culhane-Pera, et .al

Cultural Competency
 Skills

(that translate into)
 Behaviors, Practices, Attitudes, and
 Policies
That enable an individual, agency, or
system to effectively serve culturally
diverse communities.
from The Asian Health Coalition of Illinois

Here at Hill Country MHDDC
Consumers are very diverse in their
language and culture.

61% of our Consumers are
Caucasian Americans
Many have German
backgrounds.

Our Consumers are …..

n
1% NativeAmerican

33% Hispanic
1% Asian

3% African
American

1% are “Others”

Consumers Have Many
Different Lifestyles

Lifestyles

They have many different
beliefs.

Can We Communicate?
Think Language first!
 Do we need an interpreter?
 Communicate respectfully.
 Be sensitive to the consumer and the family.
 Consider your dress, tone of voice, eye contact,
location, seating arrangement, privacy, etc.


Is our approach culturally
appropriate?
“What do you call your problem?”
“What name does it have?”
“What do you think caused your problem?”
“Why do you think it started when it did?”
From Arthur Kleinman’s question protocol in“Culture,Illness, and Care:
Clinical Lessons from Anthropologic and Cross Cultural Research”,
Ann.Intern.Med. 1978:Vol.88, pg.251-258

Important Issues to Consider…





Impact of religion.
How are women, men, elders, and children
treated in their culture?
Is there domestic violence?
Ethnic minorities generally underutilize
outpatient services, although African-Americans
are over-represented in inpatient setting.

Diagnosis






Minorities with Bipolar Disorder are often
diagnosed with schizophrenia. (Mukherjee,et al)
African Americans are over diagnosed with
schizophrenia and under diagnosed with mood
disorders. (Bell )
A mental health consumer’s addictions may not
be treated.
The elderly may not be assessed for substance
abuse or alcoholism.

Diagnosis
A person with a primary addiction problem
might not be treated for a co-occurring mental
illness.
 Learning disabilities may not be identified in
individuals with mental illness or substance
abuse.
 A person with mental retardation may not be
treated for mental illness or substance abuse.


Diagnosis
Post Traumatic Stress Disorder is often
undiagnosed in people suffering from
Domestic Abuse or other trauma.
 Children who are witnessing or are
victims of domestic abuse or another
trauma, may be misdiagnosed with
Attention Deficit Hyperactivity Disorder.


Medication Differences





Asians and Hispanics need lower doses of antipsychotics.
African Americans use the same doses of antipsychotics, but lower doses of lithium.
The elderly need lower dosages of medications.
Thus, metabolism of drugs varies with age and
ethnicity and is critical in prescribing
medications.

From “Making Room for Culture in Psychiatry” by Lin, et al.

Pain Tolerance
Men and women tolerate pain differently.
 Cultures tolerate pain differently.
 People with addictions develop a
hypersensitivity to pain.
 In certain cultures, self-inflicted pain is a
part of a religious experience.


Religion





Religious beliefs shape how the world is viewed.
Is illness a punishment? The devil’s work? An
evil spell? Bad karma?
For Hispanics, the curandero is a trusted healer.
For Lakota Sioux, the ritual Vision Quest,
praying and fasting at a holy site is life
changing.

Remember there are as many
differences
Between individuals in the same
culture as there are between
individuals in different cultures!

Two African American
families, one lesbian
and the other, multi-racial.

German Consumers
Suggestions from our Gillespie County MH staff

What generation German?
 Would they feel more comfortable
speaking in German?


A consumer reacting to internal stimuli.

German Consumers
Suggestions from our Gillespie MHC staff in Fredericksburg

They may be resistant to seeking
mental services.
They may be reluctant to take medication.
They may “keep things within the family.”
They are concerned about the stigma.

German Consumers
They may feel it’s a character flaw or a
disgrace.
 They are very concerned about
confidentiality.
 Drinking alcohol is an accepted part of
their culture.
 Teen drinking may be acceptable in their
family.


Hispanic Consumers
from the U.S. Census, 1/23/03 Houston Chronicle

Hispanics are the largest minority group in
the U.S. with 37 million people.
 Texas is approximately 32 percent
Hispanic
 11.5 % African American,
 3.3% Other
 53.1% Anglo


Treatment Issues for Hispanic
Consumers
Do we need an interpreter?
 Is the person Tejano or from Mexico?
What generation Hispanic?
Is the person using a curandero?

Treatment issues for Hispanic
Consumers
Hallucinations are natural in their
religion.
 Hearing the voice of a loved one or having
hallucinations might be an expectations
when celebrating the Day of the Dead.
 Hispanic families are patriarchal.


Hispanic Consumers and
The Day of the Dead
A man is dressed in a skeleton
costume to portray death
in a celebration of
Dia de los Muertos,
The Day of the Dead.
People visit the graves of their
dead relatives to honor them.

Native Americans

Treatment Issues for Native
American Consumers
 Impact of racism,unemployment,and poverty.
 Coping with reservation life and
assimilation in mainstream culture.
 Consider the obesity, diabetes,
hypertension, and alcoholism in adults
and fetal alcohol syndrome in children.
 High use of native healers in the Southwest.

African Americans

African Americans
from the Houston Chronicle, 1/23/03

There are 36.2 million Americans who
identify themselves as “black only.”
 37.7 million identify themselves as “black
and at least one other race.”
 11.5% of Texans are African Americans.


Treatment Issues for African
American
Assess for co-occurring substance use
disorders and alcoholism.
 Address complications of obesity,
hypertension, diabetes,congestive heart
failure, asthma, and cancer.
 Sickle cell anemia is another illness
specific to African Americans.


Treatment Issues for African
Americans
Matriarchy; Mom or grandmother are the
dominant family figures.
 Lack of male role models and intact
families.
 Extended family or the Church may be
supports.


Treatment Issues for African
Americans


There is discrimination within their own
group based on skin color, hair texture,
class, values, etc.

Treatment Issues for Asians

Asians rarely seek help until its very severe.
Asians have extremely low admissions to state hospitals.
Mental illness is considered shameful. It’s hidden.
Is an interpreter needed?

Treatment Issues for Asians
Focus on physical symptoms.
 Asians are sensitive to medication.
 Give ½ the standard dose.
 Asians may use traditional healers and
herbal medicine.
 Asians may “flush” when drinking
alcohol.


Asian Consumers

Acupuncture has been used to treat
pain, schizophrenia, depression, and addictions.

Treatment Issues for Asians
Asian Cultures are patriarchal.
 The males in the family have the authority.
 Asians are more formal and inhibited in
their social behavior.


Older Adults

Treatment Issues for Older
Adults
Are they aware they need help?

Treatment Issues for Older
Adults
Is their mental illness caused by medicine?
 Do their medical problems cause or
complicate their mental illness?
 Is there Elder Abuse?


Gay Men and Lesbian Women
May struggle with homophobia and“being in the
closet” at work and with their families.
Gay people may want marriage, children, partner
benefits, etc., but may endure legal barriers.

Gay and Lesbian Women
Gay people often have specific health
issues related to their sexual practices.
 HIV, AIDS and STD’s are still concerns
with Gay men.
 People may be grieving the death of a
partner or friends who’ve died from AIDS,
or coping with living with AIDS or being
HIV+ themselves.


Treatment Issues for Gay and
Lesbians
Explore childhood abuse issues and
Domestic Violence..
 Assess for substance use and alcoholism.
 Sex enhancing drug use may be common
among some gay men.


Physically Challenged
Can they get to treatment?
Deal with their frustration and depression
Re: their disability.
 Do they need vocational assistance?

Mentally Challenged

Treatment Issues of Mentally
Challenged
They need to have meaningful activity
and purpose in their lives.
 They need to feel acknowledged and
appreciated.
 They need safety, structure, and security.
 Lack of continuity can cause crisis!
 They may need vocational assistance.


Winona Ryder

December 12, 2001,
Winona Ryder shoplifted
$5,560.40 designer items
from Saks Fifth Avenue in
Beverley Hills.

Twice an Academy
Award Nominated
actress

She had the following 8 drugs in
her possession:
Liquid demerol
 Liquid Diazepam
 Vicodin
 Percodan
 Valium
 Morphine sulfate
 Endocet (containing Oxycodone)


Patterns of Drug Use are highly
Regional.
 Drugs,

routes of administration, street
names, patterns of use, and drug
combinations may differ greatly, not
only between individuals from
different cultures, but different parts
of the country or even different parts
of the city.

Drugs of Choice
Native Americans-alcohol
 Asians-gambling, work
 Gay Men-stimulants, amyl nitrate, ecstasy
 “Rich”-prescription drugs, Internet porn
 M.D.’s –Vicodin


Drugs of Choice
Young adults-marijuana, cigarettes
 Geriatrics-alcohol, pills
 Sex Workers-crack cocaine, IV speedballs
 Screen mentally retarded for abuse too!


How Do We Best Serve Our
Consumers?




Examine own stereotypes.
Build trust.
Use People First language!

How do we best serve our
consumers?
Pronounce the person’s name correctly.
 Get an interpreter, if necessary.
 Educate yourself from the consumer, his
family, co-workers, etc.
 Remember differences do matter!



Slide 59

Cultural Competence
Integrating Differences
into Community Services

Objectives
Understand Stigma.
 Understand Culture Competency.
 Learn Culturally competent care for
people with Mental Health, Mental
Retardation and Addictions.


We live in an world
which often separates us.
Racism
 Sexism
 Ageism
 Feminism
 Classism
 Atheism


“Different” people are
“Stigmatized”

Mentally retarded inmates in a sanitorium in Germany

Stigma
Definitions from the U. of Chicago PSR Training Manual

“Stigmas are negative attitudes about a
group that lead to depriving them of
some fair opportunities.”

Stigma is related to…..
Stereotypes
Prejudice
Discrimination

Stereotypes
from The Asian Health Coalition of Illinois

Stereotypes are exaggerated beliefs
or fixed ideas about a person or
group which is held by people and
sustained by selective perception and
selective forgetting.

Prejudice
from The Asian Health Coalition of Illinois

Prejudice is a preconceived idea or
negative attitude formed before the
facts are known and sustained over
generalizations. A bias without
reason, resisting all evidence…

Discrimination
from The Asian Health Coalition of Illinois

Discrimination refers to treatment in
favor or against a person based on
the group to which that person
belongs and not on merit.

Stigmatized People…..
Experience being stereotyped and
are often the object of
discrimination and prejudice.

People are often stigmatized by:













Mental Illness
Mental Retardation
Physical Disability (including blindness, deafness)
Alcoholism /and or Drug Addiction
HIV or AIDS, Cancer or other terminal illnesses
Criminal behavior
Poverty
Alternative Lifestyles/sexual orientation
Wheelchair bound
Gender
Obesity

All our Consumers belong to
stigmatized groups!

Stigmatized People
Consumers and their families
can’t navigate the bureaucracy
even if resources are there.
It’s too frustrating!

Use People First Language
“I am more than my
illness….Don’t call me
“the schizophrenic,
“the addict” or
“the retard.”

As human beings, we have many
similarities…..
But, who we really are, is often
derived from our original family of origin
and our current lifestyle.

The Bottom Line:
People are different, even within
their own culture!
These differences matter when
planning and providing services.

National Mental Health
Association
“For Mental Health consumers, both
access to the services and the effectiveness
of the care they receive are greatly affected
by the degree to which the delivery system
is“culturally competent.”

Some important definitions
Related to Cultural Competency

Culture

from King,et. al

The Office of Special Programs, U.S. Dept. of Education

“The integrated patterns of human
behavior that includes thoughts,
communications, actions, customs,
beliefs,values, and institutions of
racial, ethnic, religious, or social
groups.”

Cultural Sensitivity
An awareness and respect of a
person’s cultural beliefs and
values.
Culhane-Pera, et .al

Cultural Competency
 Skills

(that translate into)
 Behaviors, Practices, Attitudes, and
 Policies
That enable an individual, agency, or
system to effectively serve culturally
diverse communities.
from The Asian Health Coalition of Illinois

Here at Hill Country MHDDC
Consumers are very diverse in their
language and culture.

61% of our Consumers are
Caucasian Americans
Many have German
backgrounds.

Our Consumers are …..

n
1% NativeAmerican

33% Hispanic
1% Asian

3% African
American

1% are “Others”

Consumers Have Many
Different Lifestyles

Lifestyles

They have many different
beliefs.

Can We Communicate?
Think Language first!
 Do we need an interpreter?
 Communicate respectfully.
 Be sensitive to the consumer and the family.
 Consider your dress, tone of voice, eye contact,
location, seating arrangement, privacy, etc.


Is our approach culturally
appropriate?
“What do you call your problem?”
“What name does it have?”
“What do you think caused your problem?”
“Why do you think it started when it did?”
From Arthur Kleinman’s question protocol in“Culture,Illness, and Care:
Clinical Lessons from Anthropologic and Cross Cultural Research”,
Ann.Intern.Med. 1978:Vol.88, pg.251-258

Important Issues to Consider…





Impact of religion.
How are women, men, elders, and children
treated in their culture?
Is there domestic violence?
Ethnic minorities generally underutilize
outpatient services, although African-Americans
are over-represented in inpatient setting.

Diagnosis






Minorities with Bipolar Disorder are often
diagnosed with schizophrenia. (Mukherjee,et al)
African Americans are over diagnosed with
schizophrenia and under diagnosed with mood
disorders. (Bell )
A mental health consumer’s addictions may not
be treated.
The elderly may not be assessed for substance
abuse or alcoholism.

Diagnosis
A person with a primary addiction problem
might not be treated for a co-occurring mental
illness.
 Learning disabilities may not be identified in
individuals with mental illness or substance
abuse.
 A person with mental retardation may not be
treated for mental illness or substance abuse.


Diagnosis
Post Traumatic Stress Disorder is often
undiagnosed in people suffering from
Domestic Abuse or other trauma.
 Children who are witnessing or are
victims of domestic abuse or another
trauma, may be misdiagnosed with
Attention Deficit Hyperactivity Disorder.


Medication Differences





Asians and Hispanics need lower doses of antipsychotics.
African Americans use the same doses of antipsychotics, but lower doses of lithium.
The elderly need lower dosages of medications.
Thus, metabolism of drugs varies with age and
ethnicity and is critical in prescribing
medications.

From “Making Room for Culture in Psychiatry” by Lin, et al.

Pain Tolerance
Men and women tolerate pain differently.
 Cultures tolerate pain differently.
 People with addictions develop a
hypersensitivity to pain.
 In certain cultures, self-inflicted pain is a
part of a religious experience.


Religion





Religious beliefs shape how the world is viewed.
Is illness a punishment? The devil’s work? An
evil spell? Bad karma?
For Hispanics, the curandero is a trusted healer.
For Lakota Sioux, the ritual Vision Quest,
praying and fasting at a holy site is life
changing.

Remember there are as many
differences
Between individuals in the same
culture as there are between
individuals in different cultures!

Two African American
families, one lesbian
and the other, multi-racial.

German Consumers
Suggestions from our Gillespie County MH staff

What generation German?
 Would they feel more comfortable
speaking in German?


A consumer reacting to internal stimuli.

German Consumers
Suggestions from our Gillespie MHC staff in Fredericksburg

They may be resistant to seeking
mental services.
They may be reluctant to take medication.
They may “keep things within the family.”
They are concerned about the stigma.

German Consumers
They may feel it’s a character flaw or a
disgrace.
 They are very concerned about
confidentiality.
 Drinking alcohol is an accepted part of
their culture.
 Teen drinking may be acceptable in their
family.


Hispanic Consumers
from the U.S. Census, 1/23/03 Houston Chronicle

Hispanics are the largest minority group in
the U.S. with 37 million people.
 Texas is approximately 32 percent
Hispanic
 11.5 % African American,
 3.3% Other
 53.1% Anglo


Treatment Issues for Hispanic
Consumers
Do we need an interpreter?
 Is the person Tejano or from Mexico?
What generation Hispanic?
Is the person using a curandero?

Treatment issues for Hispanic
Consumers
Hallucinations are natural in their
religion.
 Hearing the voice of a loved one or having
hallucinations might be an expectations
when celebrating the Day of the Dead.
 Hispanic families are patriarchal.


Hispanic Consumers and
The Day of the Dead
A man is dressed in a skeleton
costume to portray death
in a celebration of
Dia de los Muertos,
The Day of the Dead.
People visit the graves of their
dead relatives to honor them.

Native Americans

Treatment Issues for Native
American Consumers
 Impact of racism,unemployment,and poverty.
 Coping with reservation life and
assimilation in mainstream culture.
 Consider the obesity, diabetes,
hypertension, and alcoholism in adults
and fetal alcohol syndrome in children.
 High use of native healers in the Southwest.

African Americans

African Americans
from the Houston Chronicle, 1/23/03

There are 36.2 million Americans who
identify themselves as “black only.”
 37.7 million identify themselves as “black
and at least one other race.”
 11.5% of Texans are African Americans.


Treatment Issues for African
American
Assess for co-occurring substance use
disorders and alcoholism.
 Address complications of obesity,
hypertension, diabetes,congestive heart
failure, asthma, and cancer.
 Sickle cell anemia is another illness
specific to African Americans.


Treatment Issues for African
Americans
Matriarchy; Mom or grandmother are the
dominant family figures.
 Lack of male role models and intact
families.
 Extended family or the Church may be
supports.


Treatment Issues for African
Americans


There is discrimination within their own
group based on skin color, hair texture,
class, values, etc.

Treatment Issues for Asians

Asians rarely seek help until its very severe.
Asians have extremely low admissions to state hospitals.
Mental illness is considered shameful. It’s hidden.
Is an interpreter needed?

Treatment Issues for Asians
Focus on physical symptoms.
 Asians are sensitive to medication.
 Give ½ the standard dose.
 Asians may use traditional healers and
herbal medicine.
 Asians may “flush” when drinking
alcohol.


Asian Consumers

Acupuncture has been used to treat
pain, schizophrenia, depression, and addictions.

Treatment Issues for Asians
Asian Cultures are patriarchal.
 The males in the family have the authority.
 Asians are more formal and inhibited in
their social behavior.


Older Adults

Treatment Issues for Older
Adults
Are they aware they need help?

Treatment Issues for Older
Adults
Is their mental illness caused by medicine?
 Do their medical problems cause or
complicate their mental illness?
 Is there Elder Abuse?


Gay Men and Lesbian Women
May struggle with homophobia and“being in the
closet” at work and with their families.
Gay people may want marriage, children, partner
benefits, etc., but may endure legal barriers.

Gay and Lesbian Women
Gay people often have specific health
issues related to their sexual practices.
 HIV, AIDS and STD’s are still concerns
with Gay men.
 People may be grieving the death of a
partner or friends who’ve died from AIDS,
or coping with living with AIDS or being
HIV+ themselves.


Treatment Issues for Gay and
Lesbians
Explore childhood abuse issues and
Domestic Violence..
 Assess for substance use and alcoholism.
 Sex enhancing drug use may be common
among some gay men.


Physically Challenged
Can they get to treatment?
Deal with their frustration and depression
Re: their disability.
 Do they need vocational assistance?

Mentally Challenged

Treatment Issues of Mentally
Challenged
They need to have meaningful activity
and purpose in their lives.
 They need to feel acknowledged and
appreciated.
 They need safety, structure, and security.
 Lack of continuity can cause crisis!
 They may need vocational assistance.


Winona Ryder

December 12, 2001,
Winona Ryder shoplifted
$5,560.40 designer items
from Saks Fifth Avenue in
Beverley Hills.

Twice an Academy
Award Nominated
actress

She had the following 8 drugs in
her possession:
Liquid demerol
 Liquid Diazepam
 Vicodin
 Percodan
 Valium
 Morphine sulfate
 Endocet (containing Oxycodone)


Patterns of Drug Use are highly
Regional.
 Drugs,

routes of administration, street
names, patterns of use, and drug
combinations may differ greatly, not
only between individuals from
different cultures, but different parts
of the country or even different parts
of the city.

Drugs of Choice
Native Americans-alcohol
 Asians-gambling, work
 Gay Men-stimulants, amyl nitrate, ecstasy
 “Rich”-prescription drugs, Internet porn
 M.D.’s –Vicodin


Drugs of Choice
Young adults-marijuana, cigarettes
 Geriatrics-alcohol, pills
 Sex Workers-crack cocaine, IV speedballs
 Screen mentally retarded for abuse too!


How Do We Best Serve Our
Consumers?




Examine own stereotypes.
Build trust.
Use People First language!

How do we best serve our
consumers?
Pronounce the person’s name correctly.
 Get an interpreter, if necessary.
 Educate yourself from the consumer, his
family, co-workers, etc.
 Remember differences do matter!



Slide 60

Cultural Competence
Integrating Differences
into Community Services

Objectives
Understand Stigma.
 Understand Culture Competency.
 Learn Culturally competent care for
people with Mental Health, Mental
Retardation and Addictions.


We live in an world
which often separates us.
Racism
 Sexism
 Ageism
 Feminism
 Classism
 Atheism


“Different” people are
“Stigmatized”

Mentally retarded inmates in a sanitorium in Germany

Stigma
Definitions from the U. of Chicago PSR Training Manual

“Stigmas are negative attitudes about a
group that lead to depriving them of
some fair opportunities.”

Stigma is related to…..
Stereotypes
Prejudice
Discrimination

Stereotypes
from The Asian Health Coalition of Illinois

Stereotypes are exaggerated beliefs
or fixed ideas about a person or
group which is held by people and
sustained by selective perception and
selective forgetting.

Prejudice
from The Asian Health Coalition of Illinois

Prejudice is a preconceived idea or
negative attitude formed before the
facts are known and sustained over
generalizations. A bias without
reason, resisting all evidence…

Discrimination
from The Asian Health Coalition of Illinois

Discrimination refers to treatment in
favor or against a person based on
the group to which that person
belongs and not on merit.

Stigmatized People…..
Experience being stereotyped and
are often the object of
discrimination and prejudice.

People are often stigmatized by:













Mental Illness
Mental Retardation
Physical Disability (including blindness, deafness)
Alcoholism /and or Drug Addiction
HIV or AIDS, Cancer or other terminal illnesses
Criminal behavior
Poverty
Alternative Lifestyles/sexual orientation
Wheelchair bound
Gender
Obesity

All our Consumers belong to
stigmatized groups!

Stigmatized People
Consumers and their families
can’t navigate the bureaucracy
even if resources are there.
It’s too frustrating!

Use People First Language
“I am more than my
illness….Don’t call me
“the schizophrenic,
“the addict” or
“the retard.”

As human beings, we have many
similarities…..
But, who we really are, is often
derived from our original family of origin
and our current lifestyle.

The Bottom Line:
People are different, even within
their own culture!
These differences matter when
planning and providing services.

National Mental Health
Association
“For Mental Health consumers, both
access to the services and the effectiveness
of the care they receive are greatly affected
by the degree to which the delivery system
is“culturally competent.”

Some important definitions
Related to Cultural Competency

Culture

from King,et. al

The Office of Special Programs, U.S. Dept. of Education

“The integrated patterns of human
behavior that includes thoughts,
communications, actions, customs,
beliefs,values, and institutions of
racial, ethnic, religious, or social
groups.”

Cultural Sensitivity
An awareness and respect of a
person’s cultural beliefs and
values.
Culhane-Pera, et .al

Cultural Competency
 Skills

(that translate into)
 Behaviors, Practices, Attitudes, and
 Policies
That enable an individual, agency, or
system to effectively serve culturally
diverse communities.
from The Asian Health Coalition of Illinois

Here at Hill Country MHDDC
Consumers are very diverse in their
language and culture.

61% of our Consumers are
Caucasian Americans
Many have German
backgrounds.

Our Consumers are …..

n
1% NativeAmerican

33% Hispanic
1% Asian

3% African
American

1% are “Others”

Consumers Have Many
Different Lifestyles

Lifestyles

They have many different
beliefs.

Can We Communicate?
Think Language first!
 Do we need an interpreter?
 Communicate respectfully.
 Be sensitive to the consumer and the family.
 Consider your dress, tone of voice, eye contact,
location, seating arrangement, privacy, etc.


Is our approach culturally
appropriate?
“What do you call your problem?”
“What name does it have?”
“What do you think caused your problem?”
“Why do you think it started when it did?”
From Arthur Kleinman’s question protocol in“Culture,Illness, and Care:
Clinical Lessons from Anthropologic and Cross Cultural Research”,
Ann.Intern.Med. 1978:Vol.88, pg.251-258

Important Issues to Consider…





Impact of religion.
How are women, men, elders, and children
treated in their culture?
Is there domestic violence?
Ethnic minorities generally underutilize
outpatient services, although African-Americans
are over-represented in inpatient setting.

Diagnosis






Minorities with Bipolar Disorder are often
diagnosed with schizophrenia. (Mukherjee,et al)
African Americans are over diagnosed with
schizophrenia and under diagnosed with mood
disorders. (Bell )
A mental health consumer’s addictions may not
be treated.
The elderly may not be assessed for substance
abuse or alcoholism.

Diagnosis
A person with a primary addiction problem
might not be treated for a co-occurring mental
illness.
 Learning disabilities may not be identified in
individuals with mental illness or substance
abuse.
 A person with mental retardation may not be
treated for mental illness or substance abuse.


Diagnosis
Post Traumatic Stress Disorder is often
undiagnosed in people suffering from
Domestic Abuse or other trauma.
 Children who are witnessing or are
victims of domestic abuse or another
trauma, may be misdiagnosed with
Attention Deficit Hyperactivity Disorder.


Medication Differences





Asians and Hispanics need lower doses of antipsychotics.
African Americans use the same doses of antipsychotics, but lower doses of lithium.
The elderly need lower dosages of medications.
Thus, metabolism of drugs varies with age and
ethnicity and is critical in prescribing
medications.

From “Making Room for Culture in Psychiatry” by Lin, et al.

Pain Tolerance
Men and women tolerate pain differently.
 Cultures tolerate pain differently.
 People with addictions develop a
hypersensitivity to pain.
 In certain cultures, self-inflicted pain is a
part of a religious experience.


Religion





Religious beliefs shape how the world is viewed.
Is illness a punishment? The devil’s work? An
evil spell? Bad karma?
For Hispanics, the curandero is a trusted healer.
For Lakota Sioux, the ritual Vision Quest,
praying and fasting at a holy site is life
changing.

Remember there are as many
differences
Between individuals in the same
culture as there are between
individuals in different cultures!

Two African American
families, one lesbian
and the other, multi-racial.

German Consumers
Suggestions from our Gillespie County MH staff

What generation German?
 Would they feel more comfortable
speaking in German?


A consumer reacting to internal stimuli.

German Consumers
Suggestions from our Gillespie MHC staff in Fredericksburg

They may be resistant to seeking
mental services.
They may be reluctant to take medication.
They may “keep things within the family.”
They are concerned about the stigma.

German Consumers
They may feel it’s a character flaw or a
disgrace.
 They are very concerned about
confidentiality.
 Drinking alcohol is an accepted part of
their culture.
 Teen drinking may be acceptable in their
family.


Hispanic Consumers
from the U.S. Census, 1/23/03 Houston Chronicle

Hispanics are the largest minority group in
the U.S. with 37 million people.
 Texas is approximately 32 percent
Hispanic
 11.5 % African American,
 3.3% Other
 53.1% Anglo


Treatment Issues for Hispanic
Consumers
Do we need an interpreter?
 Is the person Tejano or from Mexico?
What generation Hispanic?
Is the person using a curandero?

Treatment issues for Hispanic
Consumers
Hallucinations are natural in their
religion.
 Hearing the voice of a loved one or having
hallucinations might be an expectations
when celebrating the Day of the Dead.
 Hispanic families are patriarchal.


Hispanic Consumers and
The Day of the Dead
A man is dressed in a skeleton
costume to portray death
in a celebration of
Dia de los Muertos,
The Day of the Dead.
People visit the graves of their
dead relatives to honor them.

Native Americans

Treatment Issues for Native
American Consumers
 Impact of racism,unemployment,and poverty.
 Coping with reservation life and
assimilation in mainstream culture.
 Consider the obesity, diabetes,
hypertension, and alcoholism in adults
and fetal alcohol syndrome in children.
 High use of native healers in the Southwest.

African Americans

African Americans
from the Houston Chronicle, 1/23/03

There are 36.2 million Americans who
identify themselves as “black only.”
 37.7 million identify themselves as “black
and at least one other race.”
 11.5% of Texans are African Americans.


Treatment Issues for African
American
Assess for co-occurring substance use
disorders and alcoholism.
 Address complications of obesity,
hypertension, diabetes,congestive heart
failure, asthma, and cancer.
 Sickle cell anemia is another illness
specific to African Americans.


Treatment Issues for African
Americans
Matriarchy; Mom or grandmother are the
dominant family figures.
 Lack of male role models and intact
families.
 Extended family or the Church may be
supports.


Treatment Issues for African
Americans


There is discrimination within their own
group based on skin color, hair texture,
class, values, etc.

Treatment Issues for Asians

Asians rarely seek help until its very severe.
Asians have extremely low admissions to state hospitals.
Mental illness is considered shameful. It’s hidden.
Is an interpreter needed?

Treatment Issues for Asians
Focus on physical symptoms.
 Asians are sensitive to medication.
 Give ½ the standard dose.
 Asians may use traditional healers and
herbal medicine.
 Asians may “flush” when drinking
alcohol.


Asian Consumers

Acupuncture has been used to treat
pain, schizophrenia, depression, and addictions.

Treatment Issues for Asians
Asian Cultures are patriarchal.
 The males in the family have the authority.
 Asians are more formal and inhibited in
their social behavior.


Older Adults

Treatment Issues for Older
Adults
Are they aware they need help?

Treatment Issues for Older
Adults
Is their mental illness caused by medicine?
 Do their medical problems cause or
complicate their mental illness?
 Is there Elder Abuse?


Gay Men and Lesbian Women
May struggle with homophobia and“being in the
closet” at work and with their families.
Gay people may want marriage, children, partner
benefits, etc., but may endure legal barriers.

Gay and Lesbian Women
Gay people often have specific health
issues related to their sexual practices.
 HIV, AIDS and STD’s are still concerns
with Gay men.
 People may be grieving the death of a
partner or friends who’ve died from AIDS,
or coping with living with AIDS or being
HIV+ themselves.


Treatment Issues for Gay and
Lesbians
Explore childhood abuse issues and
Domestic Violence..
 Assess for substance use and alcoholism.
 Sex enhancing drug use may be common
among some gay men.


Physically Challenged
Can they get to treatment?
Deal with their frustration and depression
Re: their disability.
 Do they need vocational assistance?

Mentally Challenged

Treatment Issues of Mentally
Challenged
They need to have meaningful activity
and purpose in their lives.
 They need to feel acknowledged and
appreciated.
 They need safety, structure, and security.
 Lack of continuity can cause crisis!
 They may need vocational assistance.


Winona Ryder

December 12, 2001,
Winona Ryder shoplifted
$5,560.40 designer items
from Saks Fifth Avenue in
Beverley Hills.

Twice an Academy
Award Nominated
actress

She had the following 8 drugs in
her possession:
Liquid demerol
 Liquid Diazepam
 Vicodin
 Percodan
 Valium
 Morphine sulfate
 Endocet (containing Oxycodone)


Patterns of Drug Use are highly
Regional.
 Drugs,

routes of administration, street
names, patterns of use, and drug
combinations may differ greatly, not
only between individuals from
different cultures, but different parts
of the country or even different parts
of the city.

Drugs of Choice
Native Americans-alcohol
 Asians-gambling, work
 Gay Men-stimulants, amyl nitrate, ecstasy
 “Rich”-prescription drugs, Internet porn
 M.D.’s –Vicodin


Drugs of Choice
Young adults-marijuana, cigarettes
 Geriatrics-alcohol, pills
 Sex Workers-crack cocaine, IV speedballs
 Screen mentally retarded for abuse too!


How Do We Best Serve Our
Consumers?




Examine own stereotypes.
Build trust.
Use People First language!

How do we best serve our
consumers?
Pronounce the person’s name correctly.
 Get an interpreter, if necessary.
 Educate yourself from the consumer, his
family, co-workers, etc.
 Remember differences do matter!



Slide 61

Cultural Competence
Integrating Differences
into Community Services

Objectives
Understand Stigma.
 Understand Culture Competency.
 Learn Culturally competent care for
people with Mental Health, Mental
Retardation and Addictions.


We live in an world
which often separates us.
Racism
 Sexism
 Ageism
 Feminism
 Classism
 Atheism


“Different” people are
“Stigmatized”

Mentally retarded inmates in a sanitorium in Germany

Stigma
Definitions from the U. of Chicago PSR Training Manual

“Stigmas are negative attitudes about a
group that lead to depriving them of
some fair opportunities.”

Stigma is related to…..
Stereotypes
Prejudice
Discrimination

Stereotypes
from The Asian Health Coalition of Illinois

Stereotypes are exaggerated beliefs
or fixed ideas about a person or
group which is held by people and
sustained by selective perception and
selective forgetting.

Prejudice
from The Asian Health Coalition of Illinois

Prejudice is a preconceived idea or
negative attitude formed before the
facts are known and sustained over
generalizations. A bias without
reason, resisting all evidence…

Discrimination
from The Asian Health Coalition of Illinois

Discrimination refers to treatment in
favor or against a person based on
the group to which that person
belongs and not on merit.

Stigmatized People…..
Experience being stereotyped and
are often the object of
discrimination and prejudice.

People are often stigmatized by:













Mental Illness
Mental Retardation
Physical Disability (including blindness, deafness)
Alcoholism /and or Drug Addiction
HIV or AIDS, Cancer or other terminal illnesses
Criminal behavior
Poverty
Alternative Lifestyles/sexual orientation
Wheelchair bound
Gender
Obesity

All our Consumers belong to
stigmatized groups!

Stigmatized People
Consumers and their families
can’t navigate the bureaucracy
even if resources are there.
It’s too frustrating!

Use People First Language
“I am more than my
illness….Don’t call me
“the schizophrenic,
“the addict” or
“the retard.”

As human beings, we have many
similarities…..
But, who we really are, is often
derived from our original family of origin
and our current lifestyle.

The Bottom Line:
People are different, even within
their own culture!
These differences matter when
planning and providing services.

National Mental Health
Association
“For Mental Health consumers, both
access to the services and the effectiveness
of the care they receive are greatly affected
by the degree to which the delivery system
is“culturally competent.”

Some important definitions
Related to Cultural Competency

Culture

from King,et. al

The Office of Special Programs, U.S. Dept. of Education

“The integrated patterns of human
behavior that includes thoughts,
communications, actions, customs,
beliefs,values, and institutions of
racial, ethnic, religious, or social
groups.”

Cultural Sensitivity
An awareness and respect of a
person’s cultural beliefs and
values.
Culhane-Pera, et .al

Cultural Competency
 Skills

(that translate into)
 Behaviors, Practices, Attitudes, and
 Policies
That enable an individual, agency, or
system to effectively serve culturally
diverse communities.
from The Asian Health Coalition of Illinois

Here at Hill Country MHDDC
Consumers are very diverse in their
language and culture.

61% of our Consumers are
Caucasian Americans
Many have German
backgrounds.

Our Consumers are …..

n
1% NativeAmerican

33% Hispanic
1% Asian

3% African
American

1% are “Others”

Consumers Have Many
Different Lifestyles

Lifestyles

They have many different
beliefs.

Can We Communicate?
Think Language first!
 Do we need an interpreter?
 Communicate respectfully.
 Be sensitive to the consumer and the family.
 Consider your dress, tone of voice, eye contact,
location, seating arrangement, privacy, etc.


Is our approach culturally
appropriate?
“What do you call your problem?”
“What name does it have?”
“What do you think caused your problem?”
“Why do you think it started when it did?”
From Arthur Kleinman’s question protocol in“Culture,Illness, and Care:
Clinical Lessons from Anthropologic and Cross Cultural Research”,
Ann.Intern.Med. 1978:Vol.88, pg.251-258

Important Issues to Consider…





Impact of religion.
How are women, men, elders, and children
treated in their culture?
Is there domestic violence?
Ethnic minorities generally underutilize
outpatient services, although African-Americans
are over-represented in inpatient setting.

Diagnosis






Minorities with Bipolar Disorder are often
diagnosed with schizophrenia. (Mukherjee,et al)
African Americans are over diagnosed with
schizophrenia and under diagnosed with mood
disorders. (Bell )
A mental health consumer’s addictions may not
be treated.
The elderly may not be assessed for substance
abuse or alcoholism.

Diagnosis
A person with a primary addiction problem
might not be treated for a co-occurring mental
illness.
 Learning disabilities may not be identified in
individuals with mental illness or substance
abuse.
 A person with mental retardation may not be
treated for mental illness or substance abuse.


Diagnosis
Post Traumatic Stress Disorder is often
undiagnosed in people suffering from
Domestic Abuse or other trauma.
 Children who are witnessing or are
victims of domestic abuse or another
trauma, may be misdiagnosed with
Attention Deficit Hyperactivity Disorder.


Medication Differences





Asians and Hispanics need lower doses of antipsychotics.
African Americans use the same doses of antipsychotics, but lower doses of lithium.
The elderly need lower dosages of medications.
Thus, metabolism of drugs varies with age and
ethnicity and is critical in prescribing
medications.

From “Making Room for Culture in Psychiatry” by Lin, et al.

Pain Tolerance
Men and women tolerate pain differently.
 Cultures tolerate pain differently.
 People with addictions develop a
hypersensitivity to pain.
 In certain cultures, self-inflicted pain is a
part of a religious experience.


Religion





Religious beliefs shape how the world is viewed.
Is illness a punishment? The devil’s work? An
evil spell? Bad karma?
For Hispanics, the curandero is a trusted healer.
For Lakota Sioux, the ritual Vision Quest,
praying and fasting at a holy site is life
changing.

Remember there are as many
differences
Between individuals in the same
culture as there are between
individuals in different cultures!

Two African American
families, one lesbian
and the other, multi-racial.

German Consumers
Suggestions from our Gillespie County MH staff

What generation German?
 Would they feel more comfortable
speaking in German?


A consumer reacting to internal stimuli.

German Consumers
Suggestions from our Gillespie MHC staff in Fredericksburg

They may be resistant to seeking
mental services.
They may be reluctant to take medication.
They may “keep things within the family.”
They are concerned about the stigma.

German Consumers
They may feel it’s a character flaw or a
disgrace.
 They are very concerned about
confidentiality.
 Drinking alcohol is an accepted part of
their culture.
 Teen drinking may be acceptable in their
family.


Hispanic Consumers
from the U.S. Census, 1/23/03 Houston Chronicle

Hispanics are the largest minority group in
the U.S. with 37 million people.
 Texas is approximately 32 percent
Hispanic
 11.5 % African American,
 3.3% Other
 53.1% Anglo


Treatment Issues for Hispanic
Consumers
Do we need an interpreter?
 Is the person Tejano or from Mexico?
What generation Hispanic?
Is the person using a curandero?

Treatment issues for Hispanic
Consumers
Hallucinations are natural in their
religion.
 Hearing the voice of a loved one or having
hallucinations might be an expectations
when celebrating the Day of the Dead.
 Hispanic families are patriarchal.


Hispanic Consumers and
The Day of the Dead
A man is dressed in a skeleton
costume to portray death
in a celebration of
Dia de los Muertos,
The Day of the Dead.
People visit the graves of their
dead relatives to honor them.

Native Americans

Treatment Issues for Native
American Consumers
 Impact of racism,unemployment,and poverty.
 Coping with reservation life and
assimilation in mainstream culture.
 Consider the obesity, diabetes,
hypertension, and alcoholism in adults
and fetal alcohol syndrome in children.
 High use of native healers in the Southwest.

African Americans

African Americans
from the Houston Chronicle, 1/23/03

There are 36.2 million Americans who
identify themselves as “black only.”
 37.7 million identify themselves as “black
and at least one other race.”
 11.5% of Texans are African Americans.


Treatment Issues for African
American
Assess for co-occurring substance use
disorders and alcoholism.
 Address complications of obesity,
hypertension, diabetes,congestive heart
failure, asthma, and cancer.
 Sickle cell anemia is another illness
specific to African Americans.


Treatment Issues for African
Americans
Matriarchy; Mom or grandmother are the
dominant family figures.
 Lack of male role models and intact
families.
 Extended family or the Church may be
supports.


Treatment Issues for African
Americans


There is discrimination within their own
group based on skin color, hair texture,
class, values, etc.

Treatment Issues for Asians

Asians rarely seek help until its very severe.
Asians have extremely low admissions to state hospitals.
Mental illness is considered shameful. It’s hidden.
Is an interpreter needed?

Treatment Issues for Asians
Focus on physical symptoms.
 Asians are sensitive to medication.
 Give ½ the standard dose.
 Asians may use traditional healers and
herbal medicine.
 Asians may “flush” when drinking
alcohol.


Asian Consumers

Acupuncture has been used to treat
pain, schizophrenia, depression, and addictions.

Treatment Issues for Asians
Asian Cultures are patriarchal.
 The males in the family have the authority.
 Asians are more formal and inhibited in
their social behavior.


Older Adults

Treatment Issues for Older
Adults
Are they aware they need help?

Treatment Issues for Older
Adults
Is their mental illness caused by medicine?
 Do their medical problems cause or
complicate their mental illness?
 Is there Elder Abuse?


Gay Men and Lesbian Women
May struggle with homophobia and“being in the
closet” at work and with their families.
Gay people may want marriage, children, partner
benefits, etc., but may endure legal barriers.

Gay and Lesbian Women
Gay people often have specific health
issues related to their sexual practices.
 HIV, AIDS and STD’s are still concerns
with Gay men.
 People may be grieving the death of a
partner or friends who’ve died from AIDS,
or coping with living with AIDS or being
HIV+ themselves.


Treatment Issues for Gay and
Lesbians
Explore childhood abuse issues and
Domestic Violence..
 Assess for substance use and alcoholism.
 Sex enhancing drug use may be common
among some gay men.


Physically Challenged
Can they get to treatment?
Deal with their frustration and depression
Re: their disability.
 Do they need vocational assistance?

Mentally Challenged

Treatment Issues of Mentally
Challenged
They need to have meaningful activity
and purpose in their lives.
 They need to feel acknowledged and
appreciated.
 They need safety, structure, and security.
 Lack of continuity can cause crisis!
 They may need vocational assistance.


Winona Ryder

December 12, 2001,
Winona Ryder shoplifted
$5,560.40 designer items
from Saks Fifth Avenue in
Beverley Hills.

Twice an Academy
Award Nominated
actress

She had the following 8 drugs in
her possession:
Liquid demerol
 Liquid Diazepam
 Vicodin
 Percodan
 Valium
 Morphine sulfate
 Endocet (containing Oxycodone)


Patterns of Drug Use are highly
Regional.
 Drugs,

routes of administration, street
names, patterns of use, and drug
combinations may differ greatly, not
only between individuals from
different cultures, but different parts
of the country or even different parts
of the city.

Drugs of Choice
Native Americans-alcohol
 Asians-gambling, work
 Gay Men-stimulants, amyl nitrate, ecstasy
 “Rich”-prescription drugs, Internet porn
 M.D.’s –Vicodin


Drugs of Choice
Young adults-marijuana, cigarettes
 Geriatrics-alcohol, pills
 Sex Workers-crack cocaine, IV speedballs
 Screen mentally retarded for abuse too!


How Do We Best Serve Our
Consumers?




Examine own stereotypes.
Build trust.
Use People First language!

How do we best serve our
consumers?
Pronounce the person’s name correctly.
 Get an interpreter, if necessary.
 Educate yourself from the consumer, his
family, co-workers, etc.
 Remember differences do matter!



Slide 62

Cultural Competence
Integrating Differences
into Community Services

Objectives
Understand Stigma.
 Understand Culture Competency.
 Learn Culturally competent care for
people with Mental Health, Mental
Retardation and Addictions.


We live in an world
which often separates us.
Racism
 Sexism
 Ageism
 Feminism
 Classism
 Atheism


“Different” people are
“Stigmatized”

Mentally retarded inmates in a sanitorium in Germany

Stigma
Definitions from the U. of Chicago PSR Training Manual

“Stigmas are negative attitudes about a
group that lead to depriving them of
some fair opportunities.”

Stigma is related to…..
Stereotypes
Prejudice
Discrimination

Stereotypes
from The Asian Health Coalition of Illinois

Stereotypes are exaggerated beliefs
or fixed ideas about a person or
group which is held by people and
sustained by selective perception and
selective forgetting.

Prejudice
from The Asian Health Coalition of Illinois

Prejudice is a preconceived idea or
negative attitude formed before the
facts are known and sustained over
generalizations. A bias without
reason, resisting all evidence…

Discrimination
from The Asian Health Coalition of Illinois

Discrimination refers to treatment in
favor or against a person based on
the group to which that person
belongs and not on merit.

Stigmatized People…..
Experience being stereotyped and
are often the object of
discrimination and prejudice.

People are often stigmatized by:













Mental Illness
Mental Retardation
Physical Disability (including blindness, deafness)
Alcoholism /and or Drug Addiction
HIV or AIDS, Cancer or other terminal illnesses
Criminal behavior
Poverty
Alternative Lifestyles/sexual orientation
Wheelchair bound
Gender
Obesity

All our Consumers belong to
stigmatized groups!

Stigmatized People
Consumers and their families
can’t navigate the bureaucracy
even if resources are there.
It’s too frustrating!

Use People First Language
“I am more than my
illness….Don’t call me
“the schizophrenic,
“the addict” or
“the retard.”

As human beings, we have many
similarities…..
But, who we really are, is often
derived from our original family of origin
and our current lifestyle.

The Bottom Line:
People are different, even within
their own culture!
These differences matter when
planning and providing services.

National Mental Health
Association
“For Mental Health consumers, both
access to the services and the effectiveness
of the care they receive are greatly affected
by the degree to which the delivery system
is“culturally competent.”

Some important definitions
Related to Cultural Competency

Culture

from King,et. al

The Office of Special Programs, U.S. Dept. of Education

“The integrated patterns of human
behavior that includes thoughts,
communications, actions, customs,
beliefs,values, and institutions of
racial, ethnic, religious, or social
groups.”

Cultural Sensitivity
An awareness and respect of a
person’s cultural beliefs and
values.
Culhane-Pera, et .al

Cultural Competency
 Skills

(that translate into)
 Behaviors, Practices, Attitudes, and
 Policies
That enable an individual, agency, or
system to effectively serve culturally
diverse communities.
from The Asian Health Coalition of Illinois

Here at Hill Country MHDDC
Consumers are very diverse in their
language and culture.

61% of our Consumers are
Caucasian Americans
Many have German
backgrounds.

Our Consumers are …..

n
1% NativeAmerican

33% Hispanic
1% Asian

3% African
American

1% are “Others”

Consumers Have Many
Different Lifestyles

Lifestyles

They have many different
beliefs.

Can We Communicate?
Think Language first!
 Do we need an interpreter?
 Communicate respectfully.
 Be sensitive to the consumer and the family.
 Consider your dress, tone of voice, eye contact,
location, seating arrangement, privacy, etc.


Is our approach culturally
appropriate?
“What do you call your problem?”
“What name does it have?”
“What do you think caused your problem?”
“Why do you think it started when it did?”
From Arthur Kleinman’s question protocol in“Culture,Illness, and Care:
Clinical Lessons from Anthropologic and Cross Cultural Research”,
Ann.Intern.Med. 1978:Vol.88, pg.251-258

Important Issues to Consider…





Impact of religion.
How are women, men, elders, and children
treated in their culture?
Is there domestic violence?
Ethnic minorities generally underutilize
outpatient services, although African-Americans
are over-represented in inpatient setting.

Diagnosis






Minorities with Bipolar Disorder are often
diagnosed with schizophrenia. (Mukherjee,et al)
African Americans are over diagnosed with
schizophrenia and under diagnosed with mood
disorders. (Bell )
A mental health consumer’s addictions may not
be treated.
The elderly may not be assessed for substance
abuse or alcoholism.

Diagnosis
A person with a primary addiction problem
might not be treated for a co-occurring mental
illness.
 Learning disabilities may not be identified in
individuals with mental illness or substance
abuse.
 A person with mental retardation may not be
treated for mental illness or substance abuse.


Diagnosis
Post Traumatic Stress Disorder is often
undiagnosed in people suffering from
Domestic Abuse or other trauma.
 Children who are witnessing or are
victims of domestic abuse or another
trauma, may be misdiagnosed with
Attention Deficit Hyperactivity Disorder.


Medication Differences





Asians and Hispanics need lower doses of antipsychotics.
African Americans use the same doses of antipsychotics, but lower doses of lithium.
The elderly need lower dosages of medications.
Thus, metabolism of drugs varies with age and
ethnicity and is critical in prescribing
medications.

From “Making Room for Culture in Psychiatry” by Lin, et al.

Pain Tolerance
Men and women tolerate pain differently.
 Cultures tolerate pain differently.
 People with addictions develop a
hypersensitivity to pain.
 In certain cultures, self-inflicted pain is a
part of a religious experience.


Religion





Religious beliefs shape how the world is viewed.
Is illness a punishment? The devil’s work? An
evil spell? Bad karma?
For Hispanics, the curandero is a trusted healer.
For Lakota Sioux, the ritual Vision Quest,
praying and fasting at a holy site is life
changing.

Remember there are as many
differences
Between individuals in the same
culture as there are between
individuals in different cultures!

Two African American
families, one lesbian
and the other, multi-racial.

German Consumers
Suggestions from our Gillespie County MH staff

What generation German?
 Would they feel more comfortable
speaking in German?


A consumer reacting to internal stimuli.

German Consumers
Suggestions from our Gillespie MHC staff in Fredericksburg

They may be resistant to seeking
mental services.
They may be reluctant to take medication.
They may “keep things within the family.”
They are concerned about the stigma.

German Consumers
They may feel it’s a character flaw or a
disgrace.
 They are very concerned about
confidentiality.
 Drinking alcohol is an accepted part of
their culture.
 Teen drinking may be acceptable in their
family.


Hispanic Consumers
from the U.S. Census, 1/23/03 Houston Chronicle

Hispanics are the largest minority group in
the U.S. with 37 million people.
 Texas is approximately 32 percent
Hispanic
 11.5 % African American,
 3.3% Other
 53.1% Anglo


Treatment Issues for Hispanic
Consumers
Do we need an interpreter?
 Is the person Tejano or from Mexico?
What generation Hispanic?
Is the person using a curandero?

Treatment issues for Hispanic
Consumers
Hallucinations are natural in their
religion.
 Hearing the voice of a loved one or having
hallucinations might be an expectations
when celebrating the Day of the Dead.
 Hispanic families are patriarchal.


Hispanic Consumers and
The Day of the Dead
A man is dressed in a skeleton
costume to portray death
in a celebration of
Dia de los Muertos,
The Day of the Dead.
People visit the graves of their
dead relatives to honor them.

Native Americans

Treatment Issues for Native
American Consumers
 Impact of racism,unemployment,and poverty.
 Coping with reservation life and
assimilation in mainstream culture.
 Consider the obesity, diabetes,
hypertension, and alcoholism in adults
and fetal alcohol syndrome in children.
 High use of native healers in the Southwest.

African Americans

African Americans
from the Houston Chronicle, 1/23/03

There are 36.2 million Americans who
identify themselves as “black only.”
 37.7 million identify themselves as “black
and at least one other race.”
 11.5% of Texans are African Americans.


Treatment Issues for African
American
Assess for co-occurring substance use
disorders and alcoholism.
 Address complications of obesity,
hypertension, diabetes,congestive heart
failure, asthma, and cancer.
 Sickle cell anemia is another illness
specific to African Americans.


Treatment Issues for African
Americans
Matriarchy; Mom or grandmother are the
dominant family figures.
 Lack of male role models and intact
families.
 Extended family or the Church may be
supports.


Treatment Issues for African
Americans


There is discrimination within their own
group based on skin color, hair texture,
class, values, etc.

Treatment Issues for Asians

Asians rarely seek help until its very severe.
Asians have extremely low admissions to state hospitals.
Mental illness is considered shameful. It’s hidden.
Is an interpreter needed?

Treatment Issues for Asians
Focus on physical symptoms.
 Asians are sensitive to medication.
 Give ½ the standard dose.
 Asians may use traditional healers and
herbal medicine.
 Asians may “flush” when drinking
alcohol.


Asian Consumers

Acupuncture has been used to treat
pain, schizophrenia, depression, and addictions.

Treatment Issues for Asians
Asian Cultures are patriarchal.
 The males in the family have the authority.
 Asians are more formal and inhibited in
their social behavior.


Older Adults

Treatment Issues for Older
Adults
Are they aware they need help?

Treatment Issues for Older
Adults
Is their mental illness caused by medicine?
 Do their medical problems cause or
complicate their mental illness?
 Is there Elder Abuse?


Gay Men and Lesbian Women
May struggle with homophobia and“being in the
closet” at work and with their families.
Gay people may want marriage, children, partner
benefits, etc., but may endure legal barriers.

Gay and Lesbian Women
Gay people often have specific health
issues related to their sexual practices.
 HIV, AIDS and STD’s are still concerns
with Gay men.
 People may be grieving the death of a
partner or friends who’ve died from AIDS,
or coping with living with AIDS or being
HIV+ themselves.


Treatment Issues for Gay and
Lesbians
Explore childhood abuse issues and
Domestic Violence..
 Assess for substance use and alcoholism.
 Sex enhancing drug use may be common
among some gay men.


Physically Challenged
Can they get to treatment?
Deal with their frustration and depression
Re: their disability.
 Do they need vocational assistance?

Mentally Challenged

Treatment Issues of Mentally
Challenged
They need to have meaningful activity
and purpose in their lives.
 They need to feel acknowledged and
appreciated.
 They need safety, structure, and security.
 Lack of continuity can cause crisis!
 They may need vocational assistance.


Winona Ryder

December 12, 2001,
Winona Ryder shoplifted
$5,560.40 designer items
from Saks Fifth Avenue in
Beverley Hills.

Twice an Academy
Award Nominated
actress

She had the following 8 drugs in
her possession:
Liquid demerol
 Liquid Diazepam
 Vicodin
 Percodan
 Valium
 Morphine sulfate
 Endocet (containing Oxycodone)


Patterns of Drug Use are highly
Regional.
 Drugs,

routes of administration, street
names, patterns of use, and drug
combinations may differ greatly, not
only between individuals from
different cultures, but different parts
of the country or even different parts
of the city.

Drugs of Choice
Native Americans-alcohol
 Asians-gambling, work
 Gay Men-stimulants, amyl nitrate, ecstasy
 “Rich”-prescription drugs, Internet porn
 M.D.’s –Vicodin


Drugs of Choice
Young adults-marijuana, cigarettes
 Geriatrics-alcohol, pills
 Sex Workers-crack cocaine, IV speedballs
 Screen mentally retarded for abuse too!


How Do We Best Serve Our
Consumers?




Examine own stereotypes.
Build trust.
Use People First language!

How do we best serve our
consumers?
Pronounce the person’s name correctly.
 Get an interpreter, if necessary.
 Educate yourself from the consumer, his
family, co-workers, etc.
 Remember differences do matter!



Slide 63

Cultural Competence
Integrating Differences
into Community Services

Objectives
Understand Stigma.
 Understand Culture Competency.
 Learn Culturally competent care for
people with Mental Health, Mental
Retardation and Addictions.


We live in an world
which often separates us.
Racism
 Sexism
 Ageism
 Feminism
 Classism
 Atheism


“Different” people are
“Stigmatized”

Mentally retarded inmates in a sanitorium in Germany

Stigma
Definitions from the U. of Chicago PSR Training Manual

“Stigmas are negative attitudes about a
group that lead to depriving them of
some fair opportunities.”

Stigma is related to…..
Stereotypes
Prejudice
Discrimination

Stereotypes
from The Asian Health Coalition of Illinois

Stereotypes are exaggerated beliefs
or fixed ideas about a person or
group which is held by people and
sustained by selective perception and
selective forgetting.

Prejudice
from The Asian Health Coalition of Illinois

Prejudice is a preconceived idea or
negative attitude formed before the
facts are known and sustained over
generalizations. A bias without
reason, resisting all evidence…

Discrimination
from The Asian Health Coalition of Illinois

Discrimination refers to treatment in
favor or against a person based on
the group to which that person
belongs and not on merit.

Stigmatized People…..
Experience being stereotyped and
are often the object of
discrimination and prejudice.

People are often stigmatized by:













Mental Illness
Mental Retardation
Physical Disability (including blindness, deafness)
Alcoholism /and or Drug Addiction
HIV or AIDS, Cancer or other terminal illnesses
Criminal behavior
Poverty
Alternative Lifestyles/sexual orientation
Wheelchair bound
Gender
Obesity

All our Consumers belong to
stigmatized groups!

Stigmatized People
Consumers and their families
can’t navigate the bureaucracy
even if resources are there.
It’s too frustrating!

Use People First Language
“I am more than my
illness….Don’t call me
“the schizophrenic,
“the addict” or
“the retard.”

As human beings, we have many
similarities…..
But, who we really are, is often
derived from our original family of origin
and our current lifestyle.

The Bottom Line:
People are different, even within
their own culture!
These differences matter when
planning and providing services.

National Mental Health
Association
“For Mental Health consumers, both
access to the services and the effectiveness
of the care they receive are greatly affected
by the degree to which the delivery system
is“culturally competent.”

Some important definitions
Related to Cultural Competency

Culture

from King,et. al

The Office of Special Programs, U.S. Dept. of Education

“The integrated patterns of human
behavior that includes thoughts,
communications, actions, customs,
beliefs,values, and institutions of
racial, ethnic, religious, or social
groups.”

Cultural Sensitivity
An awareness and respect of a
person’s cultural beliefs and
values.
Culhane-Pera, et .al

Cultural Competency
 Skills

(that translate into)
 Behaviors, Practices, Attitudes, and
 Policies
That enable an individual, agency, or
system to effectively serve culturally
diverse communities.
from The Asian Health Coalition of Illinois

Here at Hill Country MHDDC
Consumers are very diverse in their
language and culture.

61% of our Consumers are
Caucasian Americans
Many have German
backgrounds.

Our Consumers are …..

n
1% NativeAmerican

33% Hispanic
1% Asian

3% African
American

1% are “Others”

Consumers Have Many
Different Lifestyles

Lifestyles

They have many different
beliefs.

Can We Communicate?
Think Language first!
 Do we need an interpreter?
 Communicate respectfully.
 Be sensitive to the consumer and the family.
 Consider your dress, tone of voice, eye contact,
location, seating arrangement, privacy, etc.


Is our approach culturally
appropriate?
“What do you call your problem?”
“What name does it have?”
“What do you think caused your problem?”
“Why do you think it started when it did?”
From Arthur Kleinman’s question protocol in“Culture,Illness, and Care:
Clinical Lessons from Anthropologic and Cross Cultural Research”,
Ann.Intern.Med. 1978:Vol.88, pg.251-258

Important Issues to Consider…





Impact of religion.
How are women, men, elders, and children
treated in their culture?
Is there domestic violence?
Ethnic minorities generally underutilize
outpatient services, although African-Americans
are over-represented in inpatient setting.

Diagnosis






Minorities with Bipolar Disorder are often
diagnosed with schizophrenia. (Mukherjee,et al)
African Americans are over diagnosed with
schizophrenia and under diagnosed with mood
disorders. (Bell )
A mental health consumer’s addictions may not
be treated.
The elderly may not be assessed for substance
abuse or alcoholism.

Diagnosis
A person with a primary addiction problem
might not be treated for a co-occurring mental
illness.
 Learning disabilities may not be identified in
individuals with mental illness or substance
abuse.
 A person with mental retardation may not be
treated for mental illness or substance abuse.


Diagnosis
Post Traumatic Stress Disorder is often
undiagnosed in people suffering from
Domestic Abuse or other trauma.
 Children who are witnessing or are
victims of domestic abuse or another
trauma, may be misdiagnosed with
Attention Deficit Hyperactivity Disorder.


Medication Differences





Asians and Hispanics need lower doses of antipsychotics.
African Americans use the same doses of antipsychotics, but lower doses of lithium.
The elderly need lower dosages of medications.
Thus, metabolism of drugs varies with age and
ethnicity and is critical in prescribing
medications.

From “Making Room for Culture in Psychiatry” by Lin, et al.

Pain Tolerance
Men and women tolerate pain differently.
 Cultures tolerate pain differently.
 People with addictions develop a
hypersensitivity to pain.
 In certain cultures, self-inflicted pain is a
part of a religious experience.


Religion





Religious beliefs shape how the world is viewed.
Is illness a punishment? The devil’s work? An
evil spell? Bad karma?
For Hispanics, the curandero is a trusted healer.
For Lakota Sioux, the ritual Vision Quest,
praying and fasting at a holy site is life
changing.

Remember there are as many
differences
Between individuals in the same
culture as there are between
individuals in different cultures!

Two African American
families, one lesbian
and the other, multi-racial.

German Consumers
Suggestions from our Gillespie County MH staff

What generation German?
 Would they feel more comfortable
speaking in German?


A consumer reacting to internal stimuli.

German Consumers
Suggestions from our Gillespie MHC staff in Fredericksburg

They may be resistant to seeking
mental services.
They may be reluctant to take medication.
They may “keep things within the family.”
They are concerned about the stigma.

German Consumers
They may feel it’s a character flaw or a
disgrace.
 They are very concerned about
confidentiality.
 Drinking alcohol is an accepted part of
their culture.
 Teen drinking may be acceptable in their
family.


Hispanic Consumers
from the U.S. Census, 1/23/03 Houston Chronicle

Hispanics are the largest minority group in
the U.S. with 37 million people.
 Texas is approximately 32 percent
Hispanic
 11.5 % African American,
 3.3% Other
 53.1% Anglo


Treatment Issues for Hispanic
Consumers
Do we need an interpreter?
 Is the person Tejano or from Mexico?
What generation Hispanic?
Is the person using a curandero?

Treatment issues for Hispanic
Consumers
Hallucinations are natural in their
religion.
 Hearing the voice of a loved one or having
hallucinations might be an expectations
when celebrating the Day of the Dead.
 Hispanic families are patriarchal.


Hispanic Consumers and
The Day of the Dead
A man is dressed in a skeleton
costume to portray death
in a celebration of
Dia de los Muertos,
The Day of the Dead.
People visit the graves of their
dead relatives to honor them.

Native Americans

Treatment Issues for Native
American Consumers
 Impact of racism,unemployment,and poverty.
 Coping with reservation life and
assimilation in mainstream culture.
 Consider the obesity, diabetes,
hypertension, and alcoholism in adults
and fetal alcohol syndrome in children.
 High use of native healers in the Southwest.

African Americans

African Americans
from the Houston Chronicle, 1/23/03

There are 36.2 million Americans who
identify themselves as “black only.”
 37.7 million identify themselves as “black
and at least one other race.”
 11.5% of Texans are African Americans.


Treatment Issues for African
American
Assess for co-occurring substance use
disorders and alcoholism.
 Address complications of obesity,
hypertension, diabetes,congestive heart
failure, asthma, and cancer.
 Sickle cell anemia is another illness
specific to African Americans.


Treatment Issues for African
Americans
Matriarchy; Mom or grandmother are the
dominant family figures.
 Lack of male role models and intact
families.
 Extended family or the Church may be
supports.


Treatment Issues for African
Americans


There is discrimination within their own
group based on skin color, hair texture,
class, values, etc.

Treatment Issues for Asians

Asians rarely seek help until its very severe.
Asians have extremely low admissions to state hospitals.
Mental illness is considered shameful. It’s hidden.
Is an interpreter needed?

Treatment Issues for Asians
Focus on physical symptoms.
 Asians are sensitive to medication.
 Give ½ the standard dose.
 Asians may use traditional healers and
herbal medicine.
 Asians may “flush” when drinking
alcohol.


Asian Consumers

Acupuncture has been used to treat
pain, schizophrenia, depression, and addictions.

Treatment Issues for Asians
Asian Cultures are patriarchal.
 The males in the family have the authority.
 Asians are more formal and inhibited in
their social behavior.


Older Adults

Treatment Issues for Older
Adults
Are they aware they need help?

Treatment Issues for Older
Adults
Is their mental illness caused by medicine?
 Do their medical problems cause or
complicate their mental illness?
 Is there Elder Abuse?


Gay Men and Lesbian Women
May struggle with homophobia and“being in the
closet” at work and with their families.
Gay people may want marriage, children, partner
benefits, etc., but may endure legal barriers.

Gay and Lesbian Women
Gay people often have specific health
issues related to their sexual practices.
 HIV, AIDS and STD’s are still concerns
with Gay men.
 People may be grieving the death of a
partner or friends who’ve died from AIDS,
or coping with living with AIDS or being
HIV+ themselves.


Treatment Issues for Gay and
Lesbians
Explore childhood abuse issues and
Domestic Violence..
 Assess for substance use and alcoholism.
 Sex enhancing drug use may be common
among some gay men.


Physically Challenged
Can they get to treatment?
Deal with their frustration and depression
Re: their disability.
 Do they need vocational assistance?

Mentally Challenged

Treatment Issues of Mentally
Challenged
They need to have meaningful activity
and purpose in their lives.
 They need to feel acknowledged and
appreciated.
 They need safety, structure, and security.
 Lack of continuity can cause crisis!
 They may need vocational assistance.


Winona Ryder

December 12, 2001,
Winona Ryder shoplifted
$5,560.40 designer items
from Saks Fifth Avenue in
Beverley Hills.

Twice an Academy
Award Nominated
actress

She had the following 8 drugs in
her possession:
Liquid demerol
 Liquid Diazepam
 Vicodin
 Percodan
 Valium
 Morphine sulfate
 Endocet (containing Oxycodone)


Patterns of Drug Use are highly
Regional.
 Drugs,

routes of administration, street
names, patterns of use, and drug
combinations may differ greatly, not
only between individuals from
different cultures, but different parts
of the country or even different parts
of the city.

Drugs of Choice
Native Americans-alcohol
 Asians-gambling, work
 Gay Men-stimulants, amyl nitrate, ecstasy
 “Rich”-prescription drugs, Internet porn
 M.D.’s –Vicodin


Drugs of Choice
Young adults-marijuana, cigarettes
 Geriatrics-alcohol, pills
 Sex Workers-crack cocaine, IV speedballs
 Screen mentally retarded for abuse too!


How Do We Best Serve Our
Consumers?




Examine own stereotypes.
Build trust.
Use People First language!

How do we best serve our
consumers?
Pronounce the person’s name correctly.
 Get an interpreter, if necessary.
 Educate yourself from the consumer, his
family, co-workers, etc.
 Remember differences do matter!



Slide 64

Cultural Competence
Integrating Differences
into Community Services

Objectives
Understand Stigma.
 Understand Culture Competency.
 Learn Culturally competent care for
people with Mental Health, Mental
Retardation and Addictions.


We live in an world
which often separates us.
Racism
 Sexism
 Ageism
 Feminism
 Classism
 Atheism


“Different” people are
“Stigmatized”

Mentally retarded inmates in a sanitorium in Germany

Stigma
Definitions from the U. of Chicago PSR Training Manual

“Stigmas are negative attitudes about a
group that lead to depriving them of
some fair opportunities.”

Stigma is related to…..
Stereotypes
Prejudice
Discrimination

Stereotypes
from The Asian Health Coalition of Illinois

Stereotypes are exaggerated beliefs
or fixed ideas about a person or
group which is held by people and
sustained by selective perception and
selective forgetting.

Prejudice
from The Asian Health Coalition of Illinois

Prejudice is a preconceived idea or
negative attitude formed before the
facts are known and sustained over
generalizations. A bias without
reason, resisting all evidence…

Discrimination
from The Asian Health Coalition of Illinois

Discrimination refers to treatment in
favor or against a person based on
the group to which that person
belongs and not on merit.

Stigmatized People…..
Experience being stereotyped and
are often the object of
discrimination and prejudice.

People are often stigmatized by:













Mental Illness
Mental Retardation
Physical Disability (including blindness, deafness)
Alcoholism /and or Drug Addiction
HIV or AIDS, Cancer or other terminal illnesses
Criminal behavior
Poverty
Alternative Lifestyles/sexual orientation
Wheelchair bound
Gender
Obesity

All our Consumers belong to
stigmatized groups!

Stigmatized People
Consumers and their families
can’t navigate the bureaucracy
even if resources are there.
It’s too frustrating!

Use People First Language
“I am more than my
illness….Don’t call me
“the schizophrenic,
“the addict” or
“the retard.”

As human beings, we have many
similarities…..
But, who we really are, is often
derived from our original family of origin
and our current lifestyle.

The Bottom Line:
People are different, even within
their own culture!
These differences matter when
planning and providing services.

National Mental Health
Association
“For Mental Health consumers, both
access to the services and the effectiveness
of the care they receive are greatly affected
by the degree to which the delivery system
is“culturally competent.”

Some important definitions
Related to Cultural Competency

Culture

from King,et. al

The Office of Special Programs, U.S. Dept. of Education

“The integrated patterns of human
behavior that includes thoughts,
communications, actions, customs,
beliefs,values, and institutions of
racial, ethnic, religious, or social
groups.”

Cultural Sensitivity
An awareness and respect of a
person’s cultural beliefs and
values.
Culhane-Pera, et .al

Cultural Competency
 Skills

(that translate into)
 Behaviors, Practices, Attitudes, and
 Policies
That enable an individual, agency, or
system to effectively serve culturally
diverse communities.
from The Asian Health Coalition of Illinois

Here at Hill Country MHDDC
Consumers are very diverse in their
language and culture.

61% of our Consumers are
Caucasian Americans
Many have German
backgrounds.

Our Consumers are …..

n
1% NativeAmerican

33% Hispanic
1% Asian

3% African
American

1% are “Others”

Consumers Have Many
Different Lifestyles

Lifestyles

They have many different
beliefs.

Can We Communicate?
Think Language first!
 Do we need an interpreter?
 Communicate respectfully.
 Be sensitive to the consumer and the family.
 Consider your dress, tone of voice, eye contact,
location, seating arrangement, privacy, etc.


Is our approach culturally
appropriate?
“What do you call your problem?”
“What name does it have?”
“What do you think caused your problem?”
“Why do you think it started when it did?”
From Arthur Kleinman’s question protocol in“Culture,Illness, and Care:
Clinical Lessons from Anthropologic and Cross Cultural Research”,
Ann.Intern.Med. 1978:Vol.88, pg.251-258

Important Issues to Consider…





Impact of religion.
How are women, men, elders, and children
treated in their culture?
Is there domestic violence?
Ethnic minorities generally underutilize
outpatient services, although African-Americans
are over-represented in inpatient setting.

Diagnosis






Minorities with Bipolar Disorder are often
diagnosed with schizophrenia. (Mukherjee,et al)
African Americans are over diagnosed with
schizophrenia and under diagnosed with mood
disorders. (Bell )
A mental health consumer’s addictions may not
be treated.
The elderly may not be assessed for substance
abuse or alcoholism.

Diagnosis
A person with a primary addiction problem
might not be treated for a co-occurring mental
illness.
 Learning disabilities may not be identified in
individuals with mental illness or substance
abuse.
 A person with mental retardation may not be
treated for mental illness or substance abuse.


Diagnosis
Post Traumatic Stress Disorder is often
undiagnosed in people suffering from
Domestic Abuse or other trauma.
 Children who are witnessing or are
victims of domestic abuse or another
trauma, may be misdiagnosed with
Attention Deficit Hyperactivity Disorder.


Medication Differences





Asians and Hispanics need lower doses of antipsychotics.
African Americans use the same doses of antipsychotics, but lower doses of lithium.
The elderly need lower dosages of medications.
Thus, metabolism of drugs varies with age and
ethnicity and is critical in prescribing
medications.

From “Making Room for Culture in Psychiatry” by Lin, et al.

Pain Tolerance
Men and women tolerate pain differently.
 Cultures tolerate pain differently.
 People with addictions develop a
hypersensitivity to pain.
 In certain cultures, self-inflicted pain is a
part of a religious experience.


Religion





Religious beliefs shape how the world is viewed.
Is illness a punishment? The devil’s work? An
evil spell? Bad karma?
For Hispanics, the curandero is a trusted healer.
For Lakota Sioux, the ritual Vision Quest,
praying and fasting at a holy site is life
changing.

Remember there are as many
differences
Between individuals in the same
culture as there are between
individuals in different cultures!

Two African American
families, one lesbian
and the other, multi-racial.

German Consumers
Suggestions from our Gillespie County MH staff

What generation German?
 Would they feel more comfortable
speaking in German?


A consumer reacting to internal stimuli.

German Consumers
Suggestions from our Gillespie MHC staff in Fredericksburg

They may be resistant to seeking
mental services.
They may be reluctant to take medication.
They may “keep things within the family.”
They are concerned about the stigma.

German Consumers
They may feel it’s a character flaw or a
disgrace.
 They are very concerned about
confidentiality.
 Drinking alcohol is an accepted part of
their culture.
 Teen drinking may be acceptable in their
family.


Hispanic Consumers
from the U.S. Census, 1/23/03 Houston Chronicle

Hispanics are the largest minority group in
the U.S. with 37 million people.
 Texas is approximately 32 percent
Hispanic
 11.5 % African American,
 3.3% Other
 53.1% Anglo


Treatment Issues for Hispanic
Consumers
Do we need an interpreter?
 Is the person Tejano or from Mexico?
What generation Hispanic?
Is the person using a curandero?

Treatment issues for Hispanic
Consumers
Hallucinations are natural in their
religion.
 Hearing the voice of a loved one or having
hallucinations might be an expectations
when celebrating the Day of the Dead.
 Hispanic families are patriarchal.


Hispanic Consumers and
The Day of the Dead
A man is dressed in a skeleton
costume to portray death
in a celebration of
Dia de los Muertos,
The Day of the Dead.
People visit the graves of their
dead relatives to honor them.

Native Americans

Treatment Issues for Native
American Consumers
 Impact of racism,unemployment,and poverty.
 Coping with reservation life and
assimilation in mainstream culture.
 Consider the obesity, diabetes,
hypertension, and alcoholism in adults
and fetal alcohol syndrome in children.
 High use of native healers in the Southwest.

African Americans

African Americans
from the Houston Chronicle, 1/23/03

There are 36.2 million Americans who
identify themselves as “black only.”
 37.7 million identify themselves as “black
and at least one other race.”
 11.5% of Texans are African Americans.


Treatment Issues for African
American
Assess for co-occurring substance use
disorders and alcoholism.
 Address complications of obesity,
hypertension, diabetes,congestive heart
failure, asthma, and cancer.
 Sickle cell anemia is another illness
specific to African Americans.


Treatment Issues for African
Americans
Matriarchy; Mom or grandmother are the
dominant family figures.
 Lack of male role models and intact
families.
 Extended family or the Church may be
supports.


Treatment Issues for African
Americans


There is discrimination within their own
group based on skin color, hair texture,
class, values, etc.

Treatment Issues for Asians

Asians rarely seek help until its very severe.
Asians have extremely low admissions to state hospitals.
Mental illness is considered shameful. It’s hidden.
Is an interpreter needed?

Treatment Issues for Asians
Focus on physical symptoms.
 Asians are sensitive to medication.
 Give ½ the standard dose.
 Asians may use traditional healers and
herbal medicine.
 Asians may “flush” when drinking
alcohol.


Asian Consumers

Acupuncture has been used to treat
pain, schizophrenia, depression, and addictions.

Treatment Issues for Asians
Asian Cultures are patriarchal.
 The males in the family have the authority.
 Asians are more formal and inhibited in
their social behavior.


Older Adults

Treatment Issues for Older
Adults
Are they aware they need help?

Treatment Issues for Older
Adults
Is their mental illness caused by medicine?
 Do their medical problems cause or
complicate their mental illness?
 Is there Elder Abuse?


Gay Men and Lesbian Women
May struggle with homophobia and“being in the
closet” at work and with their families.
Gay people may want marriage, children, partner
benefits, etc., but may endure legal barriers.

Gay and Lesbian Women
Gay people often have specific health
issues related to their sexual practices.
 HIV, AIDS and STD’s are still concerns
with Gay men.
 People may be grieving the death of a
partner or friends who’ve died from AIDS,
or coping with living with AIDS or being
HIV+ themselves.


Treatment Issues for Gay and
Lesbians
Explore childhood abuse issues and
Domestic Violence..
 Assess for substance use and alcoholism.
 Sex enhancing drug use may be common
among some gay men.


Physically Challenged
Can they get to treatment?
Deal with their frustration and depression
Re: their disability.
 Do they need vocational assistance?

Mentally Challenged

Treatment Issues of Mentally
Challenged
They need to have meaningful activity
and purpose in their lives.
 They need to feel acknowledged and
appreciated.
 They need safety, structure, and security.
 Lack of continuity can cause crisis!
 They may need vocational assistance.


Winona Ryder

December 12, 2001,
Winona Ryder shoplifted
$5,560.40 designer items
from Saks Fifth Avenue in
Beverley Hills.

Twice an Academy
Award Nominated
actress

She had the following 8 drugs in
her possession:
Liquid demerol
 Liquid Diazepam
 Vicodin
 Percodan
 Valium
 Morphine sulfate
 Endocet (containing Oxycodone)


Patterns of Drug Use are highly
Regional.
 Drugs,

routes of administration, street
names, patterns of use, and drug
combinations may differ greatly, not
only between individuals from
different cultures, but different parts
of the country or even different parts
of the city.

Drugs of Choice
Native Americans-alcohol
 Asians-gambling, work
 Gay Men-stimulants, amyl nitrate, ecstasy
 “Rich”-prescription drugs, Internet porn
 M.D.’s –Vicodin


Drugs of Choice
Young adults-marijuana, cigarettes
 Geriatrics-alcohol, pills
 Sex Workers-crack cocaine, IV speedballs
 Screen mentally retarded for abuse too!


How Do We Best Serve Our
Consumers?




Examine own stereotypes.
Build trust.
Use People First language!

How do we best serve our
consumers?
Pronounce the person’s name correctly.
 Get an interpreter, if necessary.
 Educate yourself from the consumer, his
family, co-workers, etc.
 Remember differences do matter!



Slide 65

Cultural Competence
Integrating Differences
into Community Services

Objectives
Understand Stigma.
 Understand Culture Competency.
 Learn Culturally competent care for
people with Mental Health, Mental
Retardation and Addictions.


We live in an world
which often separates us.
Racism
 Sexism
 Ageism
 Feminism
 Classism
 Atheism


“Different” people are
“Stigmatized”

Mentally retarded inmates in a sanitorium in Germany

Stigma
Definitions from the U. of Chicago PSR Training Manual

“Stigmas are negative attitudes about a
group that lead to depriving them of
some fair opportunities.”

Stigma is related to…..
Stereotypes
Prejudice
Discrimination

Stereotypes
from The Asian Health Coalition of Illinois

Stereotypes are exaggerated beliefs
or fixed ideas about a person or
group which is held by people and
sustained by selective perception and
selective forgetting.

Prejudice
from The Asian Health Coalition of Illinois

Prejudice is a preconceived idea or
negative attitude formed before the
facts are known and sustained over
generalizations. A bias without
reason, resisting all evidence…

Discrimination
from The Asian Health Coalition of Illinois

Discrimination refers to treatment in
favor or against a person based on
the group to which that person
belongs and not on merit.

Stigmatized People…..
Experience being stereotyped and
are often the object of
discrimination and prejudice.

People are often stigmatized by:













Mental Illness
Mental Retardation
Physical Disability (including blindness, deafness)
Alcoholism /and or Drug Addiction
HIV or AIDS, Cancer or other terminal illnesses
Criminal behavior
Poverty
Alternative Lifestyles/sexual orientation
Wheelchair bound
Gender
Obesity

All our Consumers belong to
stigmatized groups!

Stigmatized People
Consumers and their families
can’t navigate the bureaucracy
even if resources are there.
It’s too frustrating!

Use People First Language
“I am more than my
illness….Don’t call me
“the schizophrenic,
“the addict” or
“the retard.”

As human beings, we have many
similarities…..
But, who we really are, is often
derived from our original family of origin
and our current lifestyle.

The Bottom Line:
People are different, even within
their own culture!
These differences matter when
planning and providing services.

National Mental Health
Association
“For Mental Health consumers, both
access to the services and the effectiveness
of the care they receive are greatly affected
by the degree to which the delivery system
is“culturally competent.”

Some important definitions
Related to Cultural Competency

Culture

from King,et. al

The Office of Special Programs, U.S. Dept. of Education

“The integrated patterns of human
behavior that includes thoughts,
communications, actions, customs,
beliefs,values, and institutions of
racial, ethnic, religious, or social
groups.”

Cultural Sensitivity
An awareness and respect of a
person’s cultural beliefs and
values.
Culhane-Pera, et .al

Cultural Competency
 Skills

(that translate into)
 Behaviors, Practices, Attitudes, and
 Policies
That enable an individual, agency, or
system to effectively serve culturally
diverse communities.
from The Asian Health Coalition of Illinois

Here at Hill Country MHDDC
Consumers are very diverse in their
language and culture.

61% of our Consumers are
Caucasian Americans
Many have German
backgrounds.

Our Consumers are …..

n
1% NativeAmerican

33% Hispanic
1% Asian

3% African
American

1% are “Others”

Consumers Have Many
Different Lifestyles

Lifestyles

They have many different
beliefs.

Can We Communicate?
Think Language first!
 Do we need an interpreter?
 Communicate respectfully.
 Be sensitive to the consumer and the family.
 Consider your dress, tone of voice, eye contact,
location, seating arrangement, privacy, etc.


Is our approach culturally
appropriate?
“What do you call your problem?”
“What name does it have?”
“What do you think caused your problem?”
“Why do you think it started when it did?”
From Arthur Kleinman’s question protocol in“Culture,Illness, and Care:
Clinical Lessons from Anthropologic and Cross Cultural Research”,
Ann.Intern.Med. 1978:Vol.88, pg.251-258

Important Issues to Consider…





Impact of religion.
How are women, men, elders, and children
treated in their culture?
Is there domestic violence?
Ethnic minorities generally underutilize
outpatient services, although African-Americans
are over-represented in inpatient setting.

Diagnosis






Minorities with Bipolar Disorder are often
diagnosed with schizophrenia. (Mukherjee,et al)
African Americans are over diagnosed with
schizophrenia and under diagnosed with mood
disorders. (Bell )
A mental health consumer’s addictions may not
be treated.
The elderly may not be assessed for substance
abuse or alcoholism.

Diagnosis
A person with a primary addiction problem
might not be treated for a co-occurring mental
illness.
 Learning disabilities may not be identified in
individuals with mental illness or substance
abuse.
 A person with mental retardation may not be
treated for mental illness or substance abuse.


Diagnosis
Post Traumatic Stress Disorder is often
undiagnosed in people suffering from
Domestic Abuse or other trauma.
 Children who are witnessing or are
victims of domestic abuse or another
trauma, may be misdiagnosed with
Attention Deficit Hyperactivity Disorder.


Medication Differences





Asians and Hispanics need lower doses of antipsychotics.
African Americans use the same doses of antipsychotics, but lower doses of lithium.
The elderly need lower dosages of medications.
Thus, metabolism of drugs varies with age and
ethnicity and is critical in prescribing
medications.

From “Making Room for Culture in Psychiatry” by Lin, et al.

Pain Tolerance
Men and women tolerate pain differently.
 Cultures tolerate pain differently.
 People with addictions develop a
hypersensitivity to pain.
 In certain cultures, self-inflicted pain is a
part of a religious experience.


Religion





Religious beliefs shape how the world is viewed.
Is illness a punishment? The devil’s work? An
evil spell? Bad karma?
For Hispanics, the curandero is a trusted healer.
For Lakota Sioux, the ritual Vision Quest,
praying and fasting at a holy site is life
changing.

Remember there are as many
differences
Between individuals in the same
culture as there are between
individuals in different cultures!

Two African American
families, one lesbian
and the other, multi-racial.

German Consumers
Suggestions from our Gillespie County MH staff

What generation German?
 Would they feel more comfortable
speaking in German?


A consumer reacting to internal stimuli.

German Consumers
Suggestions from our Gillespie MHC staff in Fredericksburg

They may be resistant to seeking
mental services.
They may be reluctant to take medication.
They may “keep things within the family.”
They are concerned about the stigma.

German Consumers
They may feel it’s a character flaw or a
disgrace.
 They are very concerned about
confidentiality.
 Drinking alcohol is an accepted part of
their culture.
 Teen drinking may be acceptable in their
family.


Hispanic Consumers
from the U.S. Census, 1/23/03 Houston Chronicle

Hispanics are the largest minority group in
the U.S. with 37 million people.
 Texas is approximately 32 percent
Hispanic
 11.5 % African American,
 3.3% Other
 53.1% Anglo


Treatment Issues for Hispanic
Consumers
Do we need an interpreter?
 Is the person Tejano or from Mexico?
What generation Hispanic?
Is the person using a curandero?

Treatment issues for Hispanic
Consumers
Hallucinations are natural in their
religion.
 Hearing the voice of a loved one or having
hallucinations might be an expectations
when celebrating the Day of the Dead.
 Hispanic families are patriarchal.


Hispanic Consumers and
The Day of the Dead
A man is dressed in a skeleton
costume to portray death
in a celebration of
Dia de los Muertos,
The Day of the Dead.
People visit the graves of their
dead relatives to honor them.

Native Americans

Treatment Issues for Native
American Consumers
 Impact of racism,unemployment,and poverty.
 Coping with reservation life and
assimilation in mainstream culture.
 Consider the obesity, diabetes,
hypertension, and alcoholism in adults
and fetal alcohol syndrome in children.
 High use of native healers in the Southwest.

African Americans

African Americans
from the Houston Chronicle, 1/23/03

There are 36.2 million Americans who
identify themselves as “black only.”
 37.7 million identify themselves as “black
and at least one other race.”
 11.5% of Texans are African Americans.


Treatment Issues for African
American
Assess for co-occurring substance use
disorders and alcoholism.
 Address complications of obesity,
hypertension, diabetes,congestive heart
failure, asthma, and cancer.
 Sickle cell anemia is another illness
specific to African Americans.


Treatment Issues for African
Americans
Matriarchy; Mom or grandmother are the
dominant family figures.
 Lack of male role models and intact
families.
 Extended family or the Church may be
supports.


Treatment Issues for African
Americans


There is discrimination within their own
group based on skin color, hair texture,
class, values, etc.

Treatment Issues for Asians

Asians rarely seek help until its very severe.
Asians have extremely low admissions to state hospitals.
Mental illness is considered shameful. It’s hidden.
Is an interpreter needed?

Treatment Issues for Asians
Focus on physical symptoms.
 Asians are sensitive to medication.
 Give ½ the standard dose.
 Asians may use traditional healers and
herbal medicine.
 Asians may “flush” when drinking
alcohol.


Asian Consumers

Acupuncture has been used to treat
pain, schizophrenia, depression, and addictions.

Treatment Issues for Asians
Asian Cultures are patriarchal.
 The males in the family have the authority.
 Asians are more formal and inhibited in
their social behavior.


Older Adults

Treatment Issues for Older
Adults
Are they aware they need help?

Treatment Issues for Older
Adults
Is their mental illness caused by medicine?
 Do their medical problems cause or
complicate their mental illness?
 Is there Elder Abuse?


Gay Men and Lesbian Women
May struggle with homophobia and“being in the
closet” at work and with their families.
Gay people may want marriage, children, partner
benefits, etc., but may endure legal barriers.

Gay and Lesbian Women
Gay people often have specific health
issues related to their sexual practices.
 HIV, AIDS and STD’s are still concerns
with Gay men.
 People may be grieving the death of a
partner or friends who’ve died from AIDS,
or coping with living with AIDS or being
HIV+ themselves.


Treatment Issues for Gay and
Lesbians
Explore childhood abuse issues and
Domestic Violence..
 Assess for substance use and alcoholism.
 Sex enhancing drug use may be common
among some gay men.


Physically Challenged
Can they get to treatment?
Deal with their frustration and depression
Re: their disability.
 Do they need vocational assistance?

Mentally Challenged

Treatment Issues of Mentally
Challenged
They need to have meaningful activity
and purpose in their lives.
 They need to feel acknowledged and
appreciated.
 They need safety, structure, and security.
 Lack of continuity can cause crisis!
 They may need vocational assistance.


Winona Ryder

December 12, 2001,
Winona Ryder shoplifted
$5,560.40 designer items
from Saks Fifth Avenue in
Beverley Hills.

Twice an Academy
Award Nominated
actress

She had the following 8 drugs in
her possession:
Liquid demerol
 Liquid Diazepam
 Vicodin
 Percodan
 Valium
 Morphine sulfate
 Endocet (containing Oxycodone)


Patterns of Drug Use are highly
Regional.
 Drugs,

routes of administration, street
names, patterns of use, and drug
combinations may differ greatly, not
only between individuals from
different cultures, but different parts
of the country or even different parts
of the city.

Drugs of Choice
Native Americans-alcohol
 Asians-gambling, work
 Gay Men-stimulants, amyl nitrate, ecstasy
 “Rich”-prescription drugs, Internet porn
 M.D.’s –Vicodin


Drugs of Choice
Young adults-marijuana, cigarettes
 Geriatrics-alcohol, pills
 Sex Workers-crack cocaine, IV speedballs
 Screen mentally retarded for abuse too!


How Do We Best Serve Our
Consumers?




Examine own stereotypes.
Build trust.
Use People First language!

How do we best serve our
consumers?
Pronounce the person’s name correctly.
 Get an interpreter, if necessary.
 Educate yourself from the consumer, his
family, co-workers, etc.
 Remember differences do matter!



Slide 66

Cultural Competence
Integrating Differences
into Community Services

Objectives
Understand Stigma.
 Understand Culture Competency.
 Learn Culturally competent care for
people with Mental Health, Mental
Retardation and Addictions.


We live in an world
which often separates us.
Racism
 Sexism
 Ageism
 Feminism
 Classism
 Atheism


“Different” people are
“Stigmatized”

Mentally retarded inmates in a sanitorium in Germany

Stigma
Definitions from the U. of Chicago PSR Training Manual

“Stigmas are negative attitudes about a
group that lead to depriving them of
some fair opportunities.”

Stigma is related to…..
Stereotypes
Prejudice
Discrimination

Stereotypes
from The Asian Health Coalition of Illinois

Stereotypes are exaggerated beliefs
or fixed ideas about a person or
group which is held by people and
sustained by selective perception and
selective forgetting.

Prejudice
from The Asian Health Coalition of Illinois

Prejudice is a preconceived idea or
negative attitude formed before the
facts are known and sustained over
generalizations. A bias without
reason, resisting all evidence…

Discrimination
from The Asian Health Coalition of Illinois

Discrimination refers to treatment in
favor or against a person based on
the group to which that person
belongs and not on merit.

Stigmatized People…..
Experience being stereotyped and
are often the object of
discrimination and prejudice.

People are often stigmatized by:













Mental Illness
Mental Retardation
Physical Disability (including blindness, deafness)
Alcoholism /and or Drug Addiction
HIV or AIDS, Cancer or other terminal illnesses
Criminal behavior
Poverty
Alternative Lifestyles/sexual orientation
Wheelchair bound
Gender
Obesity

All our Consumers belong to
stigmatized groups!

Stigmatized People
Consumers and their families
can’t navigate the bureaucracy
even if resources are there.
It’s too frustrating!

Use People First Language
“I am more than my
illness….Don’t call me
“the schizophrenic,
“the addict” or
“the retard.”

As human beings, we have many
similarities…..
But, who we really are, is often
derived from our original family of origin
and our current lifestyle.

The Bottom Line:
People are different, even within
their own culture!
These differences matter when
planning and providing services.

National Mental Health
Association
“For Mental Health consumers, both
access to the services and the effectiveness
of the care they receive are greatly affected
by the degree to which the delivery system
is“culturally competent.”

Some important definitions
Related to Cultural Competency

Culture

from King,et. al

The Office of Special Programs, U.S. Dept. of Education

“The integrated patterns of human
behavior that includes thoughts,
communications, actions, customs,
beliefs,values, and institutions of
racial, ethnic, religious, or social
groups.”

Cultural Sensitivity
An awareness and respect of a
person’s cultural beliefs and
values.
Culhane-Pera, et .al

Cultural Competency
 Skills

(that translate into)
 Behaviors, Practices, Attitudes, and
 Policies
That enable an individual, agency, or
system to effectively serve culturally
diverse communities.
from The Asian Health Coalition of Illinois

Here at Hill Country MHDDC
Consumers are very diverse in their
language and culture.

61% of our Consumers are
Caucasian Americans
Many have German
backgrounds.

Our Consumers are …..

n
1% NativeAmerican

33% Hispanic
1% Asian

3% African
American

1% are “Others”

Consumers Have Many
Different Lifestyles

Lifestyles

They have many different
beliefs.

Can We Communicate?
Think Language first!
 Do we need an interpreter?
 Communicate respectfully.
 Be sensitive to the consumer and the family.
 Consider your dress, tone of voice, eye contact,
location, seating arrangement, privacy, etc.


Is our approach culturally
appropriate?
“What do you call your problem?”
“What name does it have?”
“What do you think caused your problem?”
“Why do you think it started when it did?”
From Arthur Kleinman’s question protocol in“Culture,Illness, and Care:
Clinical Lessons from Anthropologic and Cross Cultural Research”,
Ann.Intern.Med. 1978:Vol.88, pg.251-258

Important Issues to Consider…





Impact of religion.
How are women, men, elders, and children
treated in their culture?
Is there domestic violence?
Ethnic minorities generally underutilize
outpatient services, although African-Americans
are over-represented in inpatient setting.

Diagnosis






Minorities with Bipolar Disorder are often
diagnosed with schizophrenia. (Mukherjee,et al)
African Americans are over diagnosed with
schizophrenia and under diagnosed with mood
disorders. (Bell )
A mental health consumer’s addictions may not
be treated.
The elderly may not be assessed for substance
abuse or alcoholism.

Diagnosis
A person with a primary addiction problem
might not be treated for a co-occurring mental
illness.
 Learning disabilities may not be identified in
individuals with mental illness or substance
abuse.
 A person with mental retardation may not be
treated for mental illness or substance abuse.


Diagnosis
Post Traumatic Stress Disorder is often
undiagnosed in people suffering from
Domestic Abuse or other trauma.
 Children who are witnessing or are
victims of domestic abuse or another
trauma, may be misdiagnosed with
Attention Deficit Hyperactivity Disorder.


Medication Differences





Asians and Hispanics need lower doses of antipsychotics.
African Americans use the same doses of antipsychotics, but lower doses of lithium.
The elderly need lower dosages of medications.
Thus, metabolism of drugs varies with age and
ethnicity and is critical in prescribing
medications.

From “Making Room for Culture in Psychiatry” by Lin, et al.

Pain Tolerance
Men and women tolerate pain differently.
 Cultures tolerate pain differently.
 People with addictions develop a
hypersensitivity to pain.
 In certain cultures, self-inflicted pain is a
part of a religious experience.


Religion





Religious beliefs shape how the world is viewed.
Is illness a punishment? The devil’s work? An
evil spell? Bad karma?
For Hispanics, the curandero is a trusted healer.
For Lakota Sioux, the ritual Vision Quest,
praying and fasting at a holy site is life
changing.

Remember there are as many
differences
Between individuals in the same
culture as there are between
individuals in different cultures!

Two African American
families, one lesbian
and the other, multi-racial.

German Consumers
Suggestions from our Gillespie County MH staff

What generation German?
 Would they feel more comfortable
speaking in German?


A consumer reacting to internal stimuli.

German Consumers
Suggestions from our Gillespie MHC staff in Fredericksburg

They may be resistant to seeking
mental services.
They may be reluctant to take medication.
They may “keep things within the family.”
They are concerned about the stigma.

German Consumers
They may feel it’s a character flaw or a
disgrace.
 They are very concerned about
confidentiality.
 Drinking alcohol is an accepted part of
their culture.
 Teen drinking may be acceptable in their
family.


Hispanic Consumers
from the U.S. Census, 1/23/03 Houston Chronicle

Hispanics are the largest minority group in
the U.S. with 37 million people.
 Texas is approximately 32 percent
Hispanic
 11.5 % African American,
 3.3% Other
 53.1% Anglo


Treatment Issues for Hispanic
Consumers
Do we need an interpreter?
 Is the person Tejano or from Mexico?
What generation Hispanic?
Is the person using a curandero?

Treatment issues for Hispanic
Consumers
Hallucinations are natural in their
religion.
 Hearing the voice of a loved one or having
hallucinations might be an expectations
when celebrating the Day of the Dead.
 Hispanic families are patriarchal.


Hispanic Consumers and
The Day of the Dead
A man is dressed in a skeleton
costume to portray death
in a celebration of
Dia de los Muertos,
The Day of the Dead.
People visit the graves of their
dead relatives to honor them.

Native Americans

Treatment Issues for Native
American Consumers
 Impact of racism,unemployment,and poverty.
 Coping with reservation life and
assimilation in mainstream culture.
 Consider the obesity, diabetes,
hypertension, and alcoholism in adults
and fetal alcohol syndrome in children.
 High use of native healers in the Southwest.

African Americans

African Americans
from the Houston Chronicle, 1/23/03

There are 36.2 million Americans who
identify themselves as “black only.”
 37.7 million identify themselves as “black
and at least one other race.”
 11.5% of Texans are African Americans.


Treatment Issues for African
American
Assess for co-occurring substance use
disorders and alcoholism.
 Address complications of obesity,
hypertension, diabetes,congestive heart
failure, asthma, and cancer.
 Sickle cell anemia is another illness
specific to African Americans.


Treatment Issues for African
Americans
Matriarchy; Mom or grandmother are the
dominant family figures.
 Lack of male role models and intact
families.
 Extended family or the Church may be
supports.


Treatment Issues for African
Americans


There is discrimination within their own
group based on skin color, hair texture,
class, values, etc.

Treatment Issues for Asians

Asians rarely seek help until its very severe.
Asians have extremely low admissions to state hospitals.
Mental illness is considered shameful. It’s hidden.
Is an interpreter needed?

Treatment Issues for Asians
Focus on physical symptoms.
 Asians are sensitive to medication.
 Give ½ the standard dose.
 Asians may use traditional healers and
herbal medicine.
 Asians may “flush” when drinking
alcohol.


Asian Consumers

Acupuncture has been used to treat
pain, schizophrenia, depression, and addictions.

Treatment Issues for Asians
Asian Cultures are patriarchal.
 The males in the family have the authority.
 Asians are more formal and inhibited in
their social behavior.


Older Adults

Treatment Issues for Older
Adults
Are they aware they need help?

Treatment Issues for Older
Adults
Is their mental illness caused by medicine?
 Do their medical problems cause or
complicate their mental illness?
 Is there Elder Abuse?


Gay Men and Lesbian Women
May struggle with homophobia and“being in the
closet” at work and with their families.
Gay people may want marriage, children, partner
benefits, etc., but may endure legal barriers.

Gay and Lesbian Women
Gay people often have specific health
issues related to their sexual practices.
 HIV, AIDS and STD’s are still concerns
with Gay men.
 People may be grieving the death of a
partner or friends who’ve died from AIDS,
or coping with living with AIDS or being
HIV+ themselves.


Treatment Issues for Gay and
Lesbians
Explore childhood abuse issues and
Domestic Violence..
 Assess for substance use and alcoholism.
 Sex enhancing drug use may be common
among some gay men.


Physically Challenged
Can they get to treatment?
Deal with their frustration and depression
Re: their disability.
 Do they need vocational assistance?

Mentally Challenged

Treatment Issues of Mentally
Challenged
They need to have meaningful activity
and purpose in their lives.
 They need to feel acknowledged and
appreciated.
 They need safety, structure, and security.
 Lack of continuity can cause crisis!
 They may need vocational assistance.


Winona Ryder

December 12, 2001,
Winona Ryder shoplifted
$5,560.40 designer items
from Saks Fifth Avenue in
Beverley Hills.

Twice an Academy
Award Nominated
actress

She had the following 8 drugs in
her possession:
Liquid demerol
 Liquid Diazepam
 Vicodin
 Percodan
 Valium
 Morphine sulfate
 Endocet (containing Oxycodone)


Patterns of Drug Use are highly
Regional.
 Drugs,

routes of administration, street
names, patterns of use, and drug
combinations may differ greatly, not
only between individuals from
different cultures, but different parts
of the country or even different parts
of the city.

Drugs of Choice
Native Americans-alcohol
 Asians-gambling, work
 Gay Men-stimulants, amyl nitrate, ecstasy
 “Rich”-prescription drugs, Internet porn
 M.D.’s –Vicodin


Drugs of Choice
Young adults-marijuana, cigarettes
 Geriatrics-alcohol, pills
 Sex Workers-crack cocaine, IV speedballs
 Screen mentally retarded for abuse too!


How Do We Best Serve Our
Consumers?




Examine own stereotypes.
Build trust.
Use People First language!

How do we best serve our
consumers?
Pronounce the person’s name correctly.
 Get an interpreter, if necessary.
 Educate yourself from the consumer, his
family, co-workers, etc.
 Remember differences do matter!



Slide 67

Cultural Competence
Integrating Differences
into Community Services

Objectives
Understand Stigma.
 Understand Culture Competency.
 Learn Culturally competent care for
people with Mental Health, Mental
Retardation and Addictions.


We live in an world
which often separates us.
Racism
 Sexism
 Ageism
 Feminism
 Classism
 Atheism


“Different” people are
“Stigmatized”

Mentally retarded inmates in a sanitorium in Germany

Stigma
Definitions from the U. of Chicago PSR Training Manual

“Stigmas are negative attitudes about a
group that lead to depriving them of
some fair opportunities.”

Stigma is related to…..
Stereotypes
Prejudice
Discrimination

Stereotypes
from The Asian Health Coalition of Illinois

Stereotypes are exaggerated beliefs
or fixed ideas about a person or
group which is held by people and
sustained by selective perception and
selective forgetting.

Prejudice
from The Asian Health Coalition of Illinois

Prejudice is a preconceived idea or
negative attitude formed before the
facts are known and sustained over
generalizations. A bias without
reason, resisting all evidence…

Discrimination
from The Asian Health Coalition of Illinois

Discrimination refers to treatment in
favor or against a person based on
the group to which that person
belongs and not on merit.

Stigmatized People…..
Experience being stereotyped and
are often the object of
discrimination and prejudice.

People are often stigmatized by:













Mental Illness
Mental Retardation
Physical Disability (including blindness, deafness)
Alcoholism /and or Drug Addiction
HIV or AIDS, Cancer or other terminal illnesses
Criminal behavior
Poverty
Alternative Lifestyles/sexual orientation
Wheelchair bound
Gender
Obesity

All our Consumers belong to
stigmatized groups!

Stigmatized People
Consumers and their families
can’t navigate the bureaucracy
even if resources are there.
It’s too frustrating!

Use People First Language
“I am more than my
illness….Don’t call me
“the schizophrenic,
“the addict” or
“the retard.”

As human beings, we have many
similarities…..
But, who we really are, is often
derived from our original family of origin
and our current lifestyle.

The Bottom Line:
People are different, even within
their own culture!
These differences matter when
planning and providing services.

National Mental Health
Association
“For Mental Health consumers, both
access to the services and the effectiveness
of the care they receive are greatly affected
by the degree to which the delivery system
is“culturally competent.”

Some important definitions
Related to Cultural Competency

Culture

from King,et. al

The Office of Special Programs, U.S. Dept. of Education

“The integrated patterns of human
behavior that includes thoughts,
communications, actions, customs,
beliefs,values, and institutions of
racial, ethnic, religious, or social
groups.”

Cultural Sensitivity
An awareness and respect of a
person’s cultural beliefs and
values.
Culhane-Pera, et .al

Cultural Competency
 Skills

(that translate into)
 Behaviors, Practices, Attitudes, and
 Policies
That enable an individual, agency, or
system to effectively serve culturally
diverse communities.
from The Asian Health Coalition of Illinois

Here at Hill Country MHDDC
Consumers are very diverse in their
language and culture.

61% of our Consumers are
Caucasian Americans
Many have German
backgrounds.

Our Consumers are …..

n
1% NativeAmerican

33% Hispanic
1% Asian

3% African
American

1% are “Others”

Consumers Have Many
Different Lifestyles

Lifestyles

They have many different
beliefs.

Can We Communicate?
Think Language first!
 Do we need an interpreter?
 Communicate respectfully.
 Be sensitive to the consumer and the family.
 Consider your dress, tone of voice, eye contact,
location, seating arrangement, privacy, etc.


Is our approach culturally
appropriate?
“What do you call your problem?”
“What name does it have?”
“What do you think caused your problem?”
“Why do you think it started when it did?”
From Arthur Kleinman’s question protocol in“Culture,Illness, and Care:
Clinical Lessons from Anthropologic and Cross Cultural Research”,
Ann.Intern.Med. 1978:Vol.88, pg.251-258

Important Issues to Consider…





Impact of religion.
How are women, men, elders, and children
treated in their culture?
Is there domestic violence?
Ethnic minorities generally underutilize
outpatient services, although African-Americans
are over-represented in inpatient setting.

Diagnosis






Minorities with Bipolar Disorder are often
diagnosed with schizophrenia. (Mukherjee,et al)
African Americans are over diagnosed with
schizophrenia and under diagnosed with mood
disorders. (Bell )
A mental health consumer’s addictions may not
be treated.
The elderly may not be assessed for substance
abuse or alcoholism.

Diagnosis
A person with a primary addiction problem
might not be treated for a co-occurring mental
illness.
 Learning disabilities may not be identified in
individuals with mental illness or substance
abuse.
 A person with mental retardation may not be
treated for mental illness or substance abuse.


Diagnosis
Post Traumatic Stress Disorder is often
undiagnosed in people suffering from
Domestic Abuse or other trauma.
 Children who are witnessing or are
victims of domestic abuse or another
trauma, may be misdiagnosed with
Attention Deficit Hyperactivity Disorder.


Medication Differences





Asians and Hispanics need lower doses of antipsychotics.
African Americans use the same doses of antipsychotics, but lower doses of lithium.
The elderly need lower dosages of medications.
Thus, metabolism of drugs varies with age and
ethnicity and is critical in prescribing
medications.

From “Making Room for Culture in Psychiatry” by Lin, et al.

Pain Tolerance
Men and women tolerate pain differently.
 Cultures tolerate pain differently.
 People with addictions develop a
hypersensitivity to pain.
 In certain cultures, self-inflicted pain is a
part of a religious experience.


Religion





Religious beliefs shape how the world is viewed.
Is illness a punishment? The devil’s work? An
evil spell? Bad karma?
For Hispanics, the curandero is a trusted healer.
For Lakota Sioux, the ritual Vision Quest,
praying and fasting at a holy site is life
changing.

Remember there are as many
differences
Between individuals in the same
culture as there are between
individuals in different cultures!

Two African American
families, one lesbian
and the other, multi-racial.

German Consumers
Suggestions from our Gillespie County MH staff

What generation German?
 Would they feel more comfortable
speaking in German?


A consumer reacting to internal stimuli.

German Consumers
Suggestions from our Gillespie MHC staff in Fredericksburg

They may be resistant to seeking
mental services.
They may be reluctant to take medication.
They may “keep things within the family.”
They are concerned about the stigma.

German Consumers
They may feel it’s a character flaw or a
disgrace.
 They are very concerned about
confidentiality.
 Drinking alcohol is an accepted part of
their culture.
 Teen drinking may be acceptable in their
family.


Hispanic Consumers
from the U.S. Census, 1/23/03 Houston Chronicle

Hispanics are the largest minority group in
the U.S. with 37 million people.
 Texas is approximately 32 percent
Hispanic
 11.5 % African American,
 3.3% Other
 53.1% Anglo


Treatment Issues for Hispanic
Consumers
Do we need an interpreter?
 Is the person Tejano or from Mexico?
What generation Hispanic?
Is the person using a curandero?

Treatment issues for Hispanic
Consumers
Hallucinations are natural in their
religion.
 Hearing the voice of a loved one or having
hallucinations might be an expectations
when celebrating the Day of the Dead.
 Hispanic families are patriarchal.


Hispanic Consumers and
The Day of the Dead
A man is dressed in a skeleton
costume to portray death
in a celebration of
Dia de los Muertos,
The Day of the Dead.
People visit the graves of their
dead relatives to honor them.

Native Americans

Treatment Issues for Native
American Consumers
 Impact of racism,unemployment,and poverty.
 Coping with reservation life and
assimilation in mainstream culture.
 Consider the obesity, diabetes,
hypertension, and alcoholism in adults
and fetal alcohol syndrome in children.
 High use of native healers in the Southwest.

African Americans

African Americans
from the Houston Chronicle, 1/23/03

There are 36.2 million Americans who
identify themselves as “black only.”
 37.7 million identify themselves as “black
and at least one other race.”
 11.5% of Texans are African Americans.


Treatment Issues for African
American
Assess for co-occurring substance use
disorders and alcoholism.
 Address complications of obesity,
hypertension, diabetes,congestive heart
failure, asthma, and cancer.
 Sickle cell anemia is another illness
specific to African Americans.


Treatment Issues for African
Americans
Matriarchy; Mom or grandmother are the
dominant family figures.
 Lack of male role models and intact
families.
 Extended family or the Church may be
supports.


Treatment Issues for African
Americans


There is discrimination within their own
group based on skin color, hair texture,
class, values, etc.

Treatment Issues for Asians

Asians rarely seek help until its very severe.
Asians have extremely low admissions to state hospitals.
Mental illness is considered shameful. It’s hidden.
Is an interpreter needed?

Treatment Issues for Asians
Focus on physical symptoms.
 Asians are sensitive to medication.
 Give ½ the standard dose.
 Asians may use traditional healers and
herbal medicine.
 Asians may “flush” when drinking
alcohol.


Asian Consumers

Acupuncture has been used to treat
pain, schizophrenia, depression, and addictions.

Treatment Issues for Asians
Asian Cultures are patriarchal.
 The males in the family have the authority.
 Asians are more formal and inhibited in
their social behavior.


Older Adults

Treatment Issues for Older
Adults
Are they aware they need help?

Treatment Issues for Older
Adults
Is their mental illness caused by medicine?
 Do their medical problems cause or
complicate their mental illness?
 Is there Elder Abuse?


Gay Men and Lesbian Women
May struggle with homophobia and“being in the
closet” at work and with their families.
Gay people may want marriage, children, partner
benefits, etc., but may endure legal barriers.

Gay and Lesbian Women
Gay people often have specific health
issues related to their sexual practices.
 HIV, AIDS and STD’s are still concerns
with Gay men.
 People may be grieving the death of a
partner or friends who’ve died from AIDS,
or coping with living with AIDS or being
HIV+ themselves.


Treatment Issues for Gay and
Lesbians
Explore childhood abuse issues and
Domestic Violence..
 Assess for substance use and alcoholism.
 Sex enhancing drug use may be common
among some gay men.


Physically Challenged
Can they get to treatment?
Deal with their frustration and depression
Re: their disability.
 Do they need vocational assistance?

Mentally Challenged

Treatment Issues of Mentally
Challenged
They need to have meaningful activity
and purpose in their lives.
 They need to feel acknowledged and
appreciated.
 They need safety, structure, and security.
 Lack of continuity can cause crisis!
 They may need vocational assistance.


Winona Ryder

December 12, 2001,
Winona Ryder shoplifted
$5,560.40 designer items
from Saks Fifth Avenue in
Beverley Hills.

Twice an Academy
Award Nominated
actress

She had the following 8 drugs in
her possession:
Liquid demerol
 Liquid Diazepam
 Vicodin
 Percodan
 Valium
 Morphine sulfate
 Endocet (containing Oxycodone)


Patterns of Drug Use are highly
Regional.
 Drugs,

routes of administration, street
names, patterns of use, and drug
combinations may differ greatly, not
only between individuals from
different cultures, but different parts
of the country or even different parts
of the city.

Drugs of Choice
Native Americans-alcohol
 Asians-gambling, work
 Gay Men-stimulants, amyl nitrate, ecstasy
 “Rich”-prescription drugs, Internet porn
 M.D.’s –Vicodin


Drugs of Choice
Young adults-marijuana, cigarettes
 Geriatrics-alcohol, pills
 Sex Workers-crack cocaine, IV speedballs
 Screen mentally retarded for abuse too!


How Do We Best Serve Our
Consumers?




Examine own stereotypes.
Build trust.
Use People First language!

How do we best serve our
consumers?
Pronounce the person’s name correctly.
 Get an interpreter, if necessary.
 Educate yourself from the consumer, his
family, co-workers, etc.
 Remember differences do matter!



Slide 68

Cultural Competence
Integrating Differences
into Community Services

Objectives
Understand Stigma.
 Understand Culture Competency.
 Learn Culturally competent care for
people with Mental Health, Mental
Retardation and Addictions.


We live in an world
which often separates us.
Racism
 Sexism
 Ageism
 Feminism
 Classism
 Atheism


“Different” people are
“Stigmatized”

Mentally retarded inmates in a sanitorium in Germany

Stigma
Definitions from the U. of Chicago PSR Training Manual

“Stigmas are negative attitudes about a
group that lead to depriving them of
some fair opportunities.”

Stigma is related to…..
Stereotypes
Prejudice
Discrimination

Stereotypes
from The Asian Health Coalition of Illinois

Stereotypes are exaggerated beliefs
or fixed ideas about a person or
group which is held by people and
sustained by selective perception and
selective forgetting.

Prejudice
from The Asian Health Coalition of Illinois

Prejudice is a preconceived idea or
negative attitude formed before the
facts are known and sustained over
generalizations. A bias without
reason, resisting all evidence…

Discrimination
from The Asian Health Coalition of Illinois

Discrimination refers to treatment in
favor or against a person based on
the group to which that person
belongs and not on merit.

Stigmatized People…..
Experience being stereotyped and
are often the object of
discrimination and prejudice.

People are often stigmatized by:













Mental Illness
Mental Retardation
Physical Disability (including blindness, deafness)
Alcoholism /and or Drug Addiction
HIV or AIDS, Cancer or other terminal illnesses
Criminal behavior
Poverty
Alternative Lifestyles/sexual orientation
Wheelchair bound
Gender
Obesity

All our Consumers belong to
stigmatized groups!

Stigmatized People
Consumers and their families
can’t navigate the bureaucracy
even if resources are there.
It’s too frustrating!

Use People First Language
“I am more than my
illness….Don’t call me
“the schizophrenic,
“the addict” or
“the retard.”

As human beings, we have many
similarities…..
But, who we really are, is often
derived from our original family of origin
and our current lifestyle.

The Bottom Line:
People are different, even within
their own culture!
These differences matter when
planning and providing services.

National Mental Health
Association
“For Mental Health consumers, both
access to the services and the effectiveness
of the care they receive are greatly affected
by the degree to which the delivery system
is“culturally competent.”

Some important definitions
Related to Cultural Competency

Culture

from King,et. al

The Office of Special Programs, U.S. Dept. of Education

“The integrated patterns of human
behavior that includes thoughts,
communications, actions, customs,
beliefs,values, and institutions of
racial, ethnic, religious, or social
groups.”

Cultural Sensitivity
An awareness and respect of a
person’s cultural beliefs and
values.
Culhane-Pera, et .al

Cultural Competency
 Skills

(that translate into)
 Behaviors, Practices, Attitudes, and
 Policies
That enable an individual, agency, or
system to effectively serve culturally
diverse communities.
from The Asian Health Coalition of Illinois

Here at Hill Country MHDDC
Consumers are very diverse in their
language and culture.

61% of our Consumers are
Caucasian Americans
Many have German
backgrounds.

Our Consumers are …..

n
1% NativeAmerican

33% Hispanic
1% Asian

3% African
American

1% are “Others”

Consumers Have Many
Different Lifestyles

Lifestyles

They have many different
beliefs.

Can We Communicate?
Think Language first!
 Do we need an interpreter?
 Communicate respectfully.
 Be sensitive to the consumer and the family.
 Consider your dress, tone of voice, eye contact,
location, seating arrangement, privacy, etc.


Is our approach culturally
appropriate?
“What do you call your problem?”
“What name does it have?”
“What do you think caused your problem?”
“Why do you think it started when it did?”
From Arthur Kleinman’s question protocol in“Culture,Illness, and Care:
Clinical Lessons from Anthropologic and Cross Cultural Research”,
Ann.Intern.Med. 1978:Vol.88, pg.251-258

Important Issues to Consider…





Impact of religion.
How are women, men, elders, and children
treated in their culture?
Is there domestic violence?
Ethnic minorities generally underutilize
outpatient services, although African-Americans
are over-represented in inpatient setting.

Diagnosis






Minorities with Bipolar Disorder are often
diagnosed with schizophrenia. (Mukherjee,et al)
African Americans are over diagnosed with
schizophrenia and under diagnosed with mood
disorders. (Bell )
A mental health consumer’s addictions may not
be treated.
The elderly may not be assessed for substance
abuse or alcoholism.

Diagnosis
A person with a primary addiction problem
might not be treated for a co-occurring mental
illness.
 Learning disabilities may not be identified in
individuals with mental illness or substance
abuse.
 A person with mental retardation may not be
treated for mental illness or substance abuse.


Diagnosis
Post Traumatic Stress Disorder is often
undiagnosed in people suffering from
Domestic Abuse or other trauma.
 Children who are witnessing or are
victims of domestic abuse or another
trauma, may be misdiagnosed with
Attention Deficit Hyperactivity Disorder.


Medication Differences





Asians and Hispanics need lower doses of antipsychotics.
African Americans use the same doses of antipsychotics, but lower doses of lithium.
The elderly need lower dosages of medications.
Thus, metabolism of drugs varies with age and
ethnicity and is critical in prescribing
medications.

From “Making Room for Culture in Psychiatry” by Lin, et al.

Pain Tolerance
Men and women tolerate pain differently.
 Cultures tolerate pain differently.
 People with addictions develop a
hypersensitivity to pain.
 In certain cultures, self-inflicted pain is a
part of a religious experience.


Religion





Religious beliefs shape how the world is viewed.
Is illness a punishment? The devil’s work? An
evil spell? Bad karma?
For Hispanics, the curandero is a trusted healer.
For Lakota Sioux, the ritual Vision Quest,
praying and fasting at a holy site is life
changing.

Remember there are as many
differences
Between individuals in the same
culture as there are between
individuals in different cultures!

Two African American
families, one lesbian
and the other, multi-racial.

German Consumers
Suggestions from our Gillespie County MH staff

What generation German?
 Would they feel more comfortable
speaking in German?


A consumer reacting to internal stimuli.

German Consumers
Suggestions from our Gillespie MHC staff in Fredericksburg

They may be resistant to seeking
mental services.
They may be reluctant to take medication.
They may “keep things within the family.”
They are concerned about the stigma.

German Consumers
They may feel it’s a character flaw or a
disgrace.
 They are very concerned about
confidentiality.
 Drinking alcohol is an accepted part of
their culture.
 Teen drinking may be acceptable in their
family.


Hispanic Consumers
from the U.S. Census, 1/23/03 Houston Chronicle

Hispanics are the largest minority group in
the U.S. with 37 million people.
 Texas is approximately 32 percent
Hispanic
 11.5 % African American,
 3.3% Other
 53.1% Anglo


Treatment Issues for Hispanic
Consumers
Do we need an interpreter?
 Is the person Tejano or from Mexico?
What generation Hispanic?
Is the person using a curandero?

Treatment issues for Hispanic
Consumers
Hallucinations are natural in their
religion.
 Hearing the voice of a loved one or having
hallucinations might be an expectations
when celebrating the Day of the Dead.
 Hispanic families are patriarchal.


Hispanic Consumers and
The Day of the Dead
A man is dressed in a skeleton
costume to portray death
in a celebration of
Dia de los Muertos,
The Day of the Dead.
People visit the graves of their
dead relatives to honor them.

Native Americans

Treatment Issues for Native
American Consumers
 Impact of racism,unemployment,and poverty.
 Coping with reservation life and
assimilation in mainstream culture.
 Consider the obesity, diabetes,
hypertension, and alcoholism in adults
and fetal alcohol syndrome in children.
 High use of native healers in the Southwest.

African Americans

African Americans
from the Houston Chronicle, 1/23/03

There are 36.2 million Americans who
identify themselves as “black only.”
 37.7 million identify themselves as “black
and at least one other race.”
 11.5% of Texans are African Americans.


Treatment Issues for African
American
Assess for co-occurring substance use
disorders and alcoholism.
 Address complications of obesity,
hypertension, diabetes,congestive heart
failure, asthma, and cancer.
 Sickle cell anemia is another illness
specific to African Americans.


Treatment Issues for African
Americans
Matriarchy; Mom or grandmother are the
dominant family figures.
 Lack of male role models and intact
families.
 Extended family or the Church may be
supports.


Treatment Issues for African
Americans


There is discrimination within their own
group based on skin color, hair texture,
class, values, etc.

Treatment Issues for Asians

Asians rarely seek help until its very severe.
Asians have extremely low admissions to state hospitals.
Mental illness is considered shameful. It’s hidden.
Is an interpreter needed?

Treatment Issues for Asians
Focus on physical symptoms.
 Asians are sensitive to medication.
 Give ½ the standard dose.
 Asians may use traditional healers and
herbal medicine.
 Asians may “flush” when drinking
alcohol.


Asian Consumers

Acupuncture has been used to treat
pain, schizophrenia, depression, and addictions.

Treatment Issues for Asians
Asian Cultures are patriarchal.
 The males in the family have the authority.
 Asians are more formal and inhibited in
their social behavior.


Older Adults

Treatment Issues for Older
Adults
Are they aware they need help?

Treatment Issues for Older
Adults
Is their mental illness caused by medicine?
 Do their medical problems cause or
complicate their mental illness?
 Is there Elder Abuse?


Gay Men and Lesbian Women
May struggle with homophobia and“being in the
closet” at work and with their families.
Gay people may want marriage, children, partner
benefits, etc., but may endure legal barriers.

Gay and Lesbian Women
Gay people often have specific health
issues related to their sexual practices.
 HIV, AIDS and STD’s are still concerns
with Gay men.
 People may be grieving the death of a
partner or friends who’ve died from AIDS,
or coping with living with AIDS or being
HIV+ themselves.


Treatment Issues for Gay and
Lesbians
Explore childhood abuse issues and
Domestic Violence..
 Assess for substance use and alcoholism.
 Sex enhancing drug use may be common
among some gay men.


Physically Challenged
Can they get to treatment?
Deal with their frustration and depression
Re: their disability.
 Do they need vocational assistance?

Mentally Challenged

Treatment Issues of Mentally
Challenged
They need to have meaningful activity
and purpose in their lives.
 They need to feel acknowledged and
appreciated.
 They need safety, structure, and security.
 Lack of continuity can cause crisis!
 They may need vocational assistance.


Winona Ryder

December 12, 2001,
Winona Ryder shoplifted
$5,560.40 designer items
from Saks Fifth Avenue in
Beverley Hills.

Twice an Academy
Award Nominated
actress

She had the following 8 drugs in
her possession:
Liquid demerol
 Liquid Diazepam
 Vicodin
 Percodan
 Valium
 Morphine sulfate
 Endocet (containing Oxycodone)


Patterns of Drug Use are highly
Regional.
 Drugs,

routes of administration, street
names, patterns of use, and drug
combinations may differ greatly, not
only between individuals from
different cultures, but different parts
of the country or even different parts
of the city.

Drugs of Choice
Native Americans-alcohol
 Asians-gambling, work
 Gay Men-stimulants, amyl nitrate, ecstasy
 “Rich”-prescription drugs, Internet porn
 M.D.’s –Vicodin


Drugs of Choice
Young adults-marijuana, cigarettes
 Geriatrics-alcohol, pills
 Sex Workers-crack cocaine, IV speedballs
 Screen mentally retarded for abuse too!


How Do We Best Serve Our
Consumers?




Examine own stereotypes.
Build trust.
Use People First language!

How do we best serve our
consumers?
Pronounce the person’s name correctly.
 Get an interpreter, if necessary.
 Educate yourself from the consumer, his
family, co-workers, etc.
 Remember differences do matter!



Slide 69

Cultural Competence
Integrating Differences
into Community Services

Objectives
Understand Stigma.
 Understand Culture Competency.
 Learn Culturally competent care for
people with Mental Health, Mental
Retardation and Addictions.


We live in an world
which often separates us.
Racism
 Sexism
 Ageism
 Feminism
 Classism
 Atheism


“Different” people are
“Stigmatized”

Mentally retarded inmates in a sanitorium in Germany

Stigma
Definitions from the U. of Chicago PSR Training Manual

“Stigmas are negative attitudes about a
group that lead to depriving them of
some fair opportunities.”

Stigma is related to…..
Stereotypes
Prejudice
Discrimination

Stereotypes
from The Asian Health Coalition of Illinois

Stereotypes are exaggerated beliefs
or fixed ideas about a person or
group which is held by people and
sustained by selective perception and
selective forgetting.

Prejudice
from The Asian Health Coalition of Illinois

Prejudice is a preconceived idea or
negative attitude formed before the
facts are known and sustained over
generalizations. A bias without
reason, resisting all evidence…

Discrimination
from The Asian Health Coalition of Illinois

Discrimination refers to treatment in
favor or against a person based on
the group to which that person
belongs and not on merit.

Stigmatized People…..
Experience being stereotyped and
are often the object of
discrimination and prejudice.

People are often stigmatized by:













Mental Illness
Mental Retardation
Physical Disability (including blindness, deafness)
Alcoholism /and or Drug Addiction
HIV or AIDS, Cancer or other terminal illnesses
Criminal behavior
Poverty
Alternative Lifestyles/sexual orientation
Wheelchair bound
Gender
Obesity

All our Consumers belong to
stigmatized groups!

Stigmatized People
Consumers and their families
can’t navigate the bureaucracy
even if resources are there.
It’s too frustrating!

Use People First Language
“I am more than my
illness….Don’t call me
“the schizophrenic,
“the addict” or
“the retard.”

As human beings, we have many
similarities…..
But, who we really are, is often
derived from our original family of origin
and our current lifestyle.

The Bottom Line:
People are different, even within
their own culture!
These differences matter when
planning and providing services.

National Mental Health
Association
“For Mental Health consumers, both
access to the services and the effectiveness
of the care they receive are greatly affected
by the degree to which the delivery system
is“culturally competent.”

Some important definitions
Related to Cultural Competency

Culture

from King,et. al

The Office of Special Programs, U.S. Dept. of Education

“The integrated patterns of human
behavior that includes thoughts,
communications, actions, customs,
beliefs,values, and institutions of
racial, ethnic, religious, or social
groups.”

Cultural Sensitivity
An awareness and respect of a
person’s cultural beliefs and
values.
Culhane-Pera, et .al

Cultural Competency
 Skills

(that translate into)
 Behaviors, Practices, Attitudes, and
 Policies
That enable an individual, agency, or
system to effectively serve culturally
diverse communities.
from The Asian Health Coalition of Illinois

Here at Hill Country MHDDC
Consumers are very diverse in their
language and culture.

61% of our Consumers are
Caucasian Americans
Many have German
backgrounds.

Our Consumers are …..

n
1% NativeAmerican

33% Hispanic
1% Asian

3% African
American

1% are “Others”

Consumers Have Many
Different Lifestyles

Lifestyles

They have many different
beliefs.

Can We Communicate?
Think Language first!
 Do we need an interpreter?
 Communicate respectfully.
 Be sensitive to the consumer and the family.
 Consider your dress, tone of voice, eye contact,
location, seating arrangement, privacy, etc.


Is our approach culturally
appropriate?
“What do you call your problem?”
“What name does it have?”
“What do you think caused your problem?”
“Why do you think it started when it did?”
From Arthur Kleinman’s question protocol in“Culture,Illness, and Care:
Clinical Lessons from Anthropologic and Cross Cultural Research”,
Ann.Intern.Med. 1978:Vol.88, pg.251-258

Important Issues to Consider…





Impact of religion.
How are women, men, elders, and children
treated in their culture?
Is there domestic violence?
Ethnic minorities generally underutilize
outpatient services, although African-Americans
are over-represented in inpatient setting.

Diagnosis






Minorities with Bipolar Disorder are often
diagnosed with schizophrenia. (Mukherjee,et al)
African Americans are over diagnosed with
schizophrenia and under diagnosed with mood
disorders. (Bell )
A mental health consumer’s addictions may not
be treated.
The elderly may not be assessed for substance
abuse or alcoholism.

Diagnosis
A person with a primary addiction problem
might not be treated for a co-occurring mental
illness.
 Learning disabilities may not be identified in
individuals with mental illness or substance
abuse.
 A person with mental retardation may not be
treated for mental illness or substance abuse.


Diagnosis
Post Traumatic Stress Disorder is often
undiagnosed in people suffering from
Domestic Abuse or other trauma.
 Children who are witnessing or are
victims of domestic abuse or another
trauma, may be misdiagnosed with
Attention Deficit Hyperactivity Disorder.


Medication Differences





Asians and Hispanics need lower doses of antipsychotics.
African Americans use the same doses of antipsychotics, but lower doses of lithium.
The elderly need lower dosages of medications.
Thus, metabolism of drugs varies with age and
ethnicity and is critical in prescribing
medications.

From “Making Room for Culture in Psychiatry” by Lin, et al.

Pain Tolerance
Men and women tolerate pain differently.
 Cultures tolerate pain differently.
 People with addictions develop a
hypersensitivity to pain.
 In certain cultures, self-inflicted pain is a
part of a religious experience.


Religion





Religious beliefs shape how the world is viewed.
Is illness a punishment? The devil’s work? An
evil spell? Bad karma?
For Hispanics, the curandero is a trusted healer.
For Lakota Sioux, the ritual Vision Quest,
praying and fasting at a holy site is life
changing.

Remember there are as many
differences
Between individuals in the same
culture as there are between
individuals in different cultures!

Two African American
families, one lesbian
and the other, multi-racial.

German Consumers
Suggestions from our Gillespie County MH staff

What generation German?
 Would they feel more comfortable
speaking in German?


A consumer reacting to internal stimuli.

German Consumers
Suggestions from our Gillespie MHC staff in Fredericksburg

They may be resistant to seeking
mental services.
They may be reluctant to take medication.
They may “keep things within the family.”
They are concerned about the stigma.

German Consumers
They may feel it’s a character flaw or a
disgrace.
 They are very concerned about
confidentiality.
 Drinking alcohol is an accepted part of
their culture.
 Teen drinking may be acceptable in their
family.


Hispanic Consumers
from the U.S. Census, 1/23/03 Houston Chronicle

Hispanics are the largest minority group in
the U.S. with 37 million people.
 Texas is approximately 32 percent
Hispanic
 11.5 % African American,
 3.3% Other
 53.1% Anglo


Treatment Issues for Hispanic
Consumers
Do we need an interpreter?
 Is the person Tejano or from Mexico?
What generation Hispanic?
Is the person using a curandero?

Treatment issues for Hispanic
Consumers
Hallucinations are natural in their
religion.
 Hearing the voice of a loved one or having
hallucinations might be an expectations
when celebrating the Day of the Dead.
 Hispanic families are patriarchal.


Hispanic Consumers and
The Day of the Dead
A man is dressed in a skeleton
costume to portray death
in a celebration of
Dia de los Muertos,
The Day of the Dead.
People visit the graves of their
dead relatives to honor them.

Native Americans

Treatment Issues for Native
American Consumers
 Impact of racism,unemployment,and poverty.
 Coping with reservation life and
assimilation in mainstream culture.
 Consider the obesity, diabetes,
hypertension, and alcoholism in adults
and fetal alcohol syndrome in children.
 High use of native healers in the Southwest.

African Americans

African Americans
from the Houston Chronicle, 1/23/03

There are 36.2 million Americans who
identify themselves as “black only.”
 37.7 million identify themselves as “black
and at least one other race.”
 11.5% of Texans are African Americans.


Treatment Issues for African
American
Assess for co-occurring substance use
disorders and alcoholism.
 Address complications of obesity,
hypertension, diabetes,congestive heart
failure, asthma, and cancer.
 Sickle cell anemia is another illness
specific to African Americans.


Treatment Issues for African
Americans
Matriarchy; Mom or grandmother are the
dominant family figures.
 Lack of male role models and intact
families.
 Extended family or the Church may be
supports.


Treatment Issues for African
Americans


There is discrimination within their own
group based on skin color, hair texture,
class, values, etc.

Treatment Issues for Asians

Asians rarely seek help until its very severe.
Asians have extremely low admissions to state hospitals.
Mental illness is considered shameful. It’s hidden.
Is an interpreter needed?

Treatment Issues for Asians
Focus on physical symptoms.
 Asians are sensitive to medication.
 Give ½ the standard dose.
 Asians may use traditional healers and
herbal medicine.
 Asians may “flush” when drinking
alcohol.


Asian Consumers

Acupuncture has been used to treat
pain, schizophrenia, depression, and addictions.

Treatment Issues for Asians
Asian Cultures are patriarchal.
 The males in the family have the authority.
 Asians are more formal and inhibited in
their social behavior.


Older Adults

Treatment Issues for Older
Adults
Are they aware they need help?

Treatment Issues for Older
Adults
Is their mental illness caused by medicine?
 Do their medical problems cause or
complicate their mental illness?
 Is there Elder Abuse?


Gay Men and Lesbian Women
May struggle with homophobia and“being in the
closet” at work and with their families.
Gay people may want marriage, children, partner
benefits, etc., but may endure legal barriers.

Gay and Lesbian Women
Gay people often have specific health
issues related to their sexual practices.
 HIV, AIDS and STD’s are still concerns
with Gay men.
 People may be grieving the death of a
partner or friends who’ve died from AIDS,
or coping with living with AIDS or being
HIV+ themselves.


Treatment Issues for Gay and
Lesbians
Explore childhood abuse issues and
Domestic Violence..
 Assess for substance use and alcoholism.
 Sex enhancing drug use may be common
among some gay men.


Physically Challenged
Can they get to treatment?
Deal with their frustration and depression
Re: their disability.
 Do they need vocational assistance?

Mentally Challenged

Treatment Issues of Mentally
Challenged
They need to have meaningful activity
and purpose in their lives.
 They need to feel acknowledged and
appreciated.
 They need safety, structure, and security.
 Lack of continuity can cause crisis!
 They may need vocational assistance.


Winona Ryder

December 12, 2001,
Winona Ryder shoplifted
$5,560.40 designer items
from Saks Fifth Avenue in
Beverley Hills.

Twice an Academy
Award Nominated
actress

She had the following 8 drugs in
her possession:
Liquid demerol
 Liquid Diazepam
 Vicodin
 Percodan
 Valium
 Morphine sulfate
 Endocet (containing Oxycodone)


Patterns of Drug Use are highly
Regional.
 Drugs,

routes of administration, street
names, patterns of use, and drug
combinations may differ greatly, not
only between individuals from
different cultures, but different parts
of the country or even different parts
of the city.

Drugs of Choice
Native Americans-alcohol
 Asians-gambling, work
 Gay Men-stimulants, amyl nitrate, ecstasy
 “Rich”-prescription drugs, Internet porn
 M.D.’s –Vicodin


Drugs of Choice
Young adults-marijuana, cigarettes
 Geriatrics-alcohol, pills
 Sex Workers-crack cocaine, IV speedballs
 Screen mentally retarded for abuse too!


How Do We Best Serve Our
Consumers?




Examine own stereotypes.
Build trust.
Use People First language!

How do we best serve our
consumers?
Pronounce the person’s name correctly.
 Get an interpreter, if necessary.
 Educate yourself from the consumer, his
family, co-workers, etc.
 Remember differences do matter!



Slide 70

Cultural Competence
Integrating Differences
into Community Services

Objectives
Understand Stigma.
 Understand Culture Competency.
 Learn Culturally competent care for
people with Mental Health, Mental
Retardation and Addictions.


We live in an world
which often separates us.
Racism
 Sexism
 Ageism
 Feminism
 Classism
 Atheism


“Different” people are
“Stigmatized”

Mentally retarded inmates in a sanitorium in Germany

Stigma
Definitions from the U. of Chicago PSR Training Manual

“Stigmas are negative attitudes about a
group that lead to depriving them of
some fair opportunities.”

Stigma is related to…..
Stereotypes
Prejudice
Discrimination

Stereotypes
from The Asian Health Coalition of Illinois

Stereotypes are exaggerated beliefs
or fixed ideas about a person or
group which is held by people and
sustained by selective perception and
selective forgetting.

Prejudice
from The Asian Health Coalition of Illinois

Prejudice is a preconceived idea or
negative attitude formed before the
facts are known and sustained over
generalizations. A bias without
reason, resisting all evidence…

Discrimination
from The Asian Health Coalition of Illinois

Discrimination refers to treatment in
favor or against a person based on
the group to which that person
belongs and not on merit.

Stigmatized People…..
Experience being stereotyped and
are often the object of
discrimination and prejudice.

People are often stigmatized by:













Mental Illness
Mental Retardation
Physical Disability (including blindness, deafness)
Alcoholism /and or Drug Addiction
HIV or AIDS, Cancer or other terminal illnesses
Criminal behavior
Poverty
Alternative Lifestyles/sexual orientation
Wheelchair bound
Gender
Obesity

All our Consumers belong to
stigmatized groups!

Stigmatized People
Consumers and their families
can’t navigate the bureaucracy
even if resources are there.
It’s too frustrating!

Use People First Language
“I am more than my
illness….Don’t call me
“the schizophrenic,
“the addict” or
“the retard.”

As human beings, we have many
similarities…..
But, who we really are, is often
derived from our original family of origin
and our current lifestyle.

The Bottom Line:
People are different, even within
their own culture!
These differences matter when
planning and providing services.

National Mental Health
Association
“For Mental Health consumers, both
access to the services and the effectiveness
of the care they receive are greatly affected
by the degree to which the delivery system
is“culturally competent.”

Some important definitions
Related to Cultural Competency

Culture

from King,et. al

The Office of Special Programs, U.S. Dept. of Education

“The integrated patterns of human
behavior that includes thoughts,
communications, actions, customs,
beliefs,values, and institutions of
racial, ethnic, religious, or social
groups.”

Cultural Sensitivity
An awareness and respect of a
person’s cultural beliefs and
values.
Culhane-Pera, et .al

Cultural Competency
 Skills

(that translate into)
 Behaviors, Practices, Attitudes, and
 Policies
That enable an individual, agency, or
system to effectively serve culturally
diverse communities.
from The Asian Health Coalition of Illinois

Here at Hill Country MHDDC
Consumers are very diverse in their
language and culture.

61% of our Consumers are
Caucasian Americans
Many have German
backgrounds.

Our Consumers are …..

n
1% NativeAmerican

33% Hispanic
1% Asian

3% African
American

1% are “Others”

Consumers Have Many
Different Lifestyles

Lifestyles

They have many different
beliefs.

Can We Communicate?
Think Language first!
 Do we need an interpreter?
 Communicate respectfully.
 Be sensitive to the consumer and the family.
 Consider your dress, tone of voice, eye contact,
location, seating arrangement, privacy, etc.


Is our approach culturally
appropriate?
“What do you call your problem?”
“What name does it have?”
“What do you think caused your problem?”
“Why do you think it started when it did?”
From Arthur Kleinman’s question protocol in“Culture,Illness, and Care:
Clinical Lessons from Anthropologic and Cross Cultural Research”,
Ann.Intern.Med. 1978:Vol.88, pg.251-258

Important Issues to Consider…





Impact of religion.
How are women, men, elders, and children
treated in their culture?
Is there domestic violence?
Ethnic minorities generally underutilize
outpatient services, although African-Americans
are over-represented in inpatient setting.

Diagnosis






Minorities with Bipolar Disorder are often
diagnosed with schizophrenia. (Mukherjee,et al)
African Americans are over diagnosed with
schizophrenia and under diagnosed with mood
disorders. (Bell )
A mental health consumer’s addictions may not
be treated.
The elderly may not be assessed for substance
abuse or alcoholism.

Diagnosis
A person with a primary addiction problem
might not be treated for a co-occurring mental
illness.
 Learning disabilities may not be identified in
individuals with mental illness or substance
abuse.
 A person with mental retardation may not be
treated for mental illness or substance abuse.


Diagnosis
Post Traumatic Stress Disorder is often
undiagnosed in people suffering from
Domestic Abuse or other trauma.
 Children who are witnessing or are
victims of domestic abuse or another
trauma, may be misdiagnosed with
Attention Deficit Hyperactivity Disorder.


Medication Differences





Asians and Hispanics need lower doses of antipsychotics.
African Americans use the same doses of antipsychotics, but lower doses of lithium.
The elderly need lower dosages of medications.
Thus, metabolism of drugs varies with age and
ethnicity and is critical in prescribing
medications.

From “Making Room for Culture in Psychiatry” by Lin, et al.

Pain Tolerance
Men and women tolerate pain differently.
 Cultures tolerate pain differently.
 People with addictions develop a
hypersensitivity to pain.
 In certain cultures, self-inflicted pain is a
part of a religious experience.


Religion





Religious beliefs shape how the world is viewed.
Is illness a punishment? The devil’s work? An
evil spell? Bad karma?
For Hispanics, the curandero is a trusted healer.
For Lakota Sioux, the ritual Vision Quest,
praying and fasting at a holy site is life
changing.

Remember there are as many
differences
Between individuals in the same
culture as there are between
individuals in different cultures!

Two African American
families, one lesbian
and the other, multi-racial.

German Consumers
Suggestions from our Gillespie County MH staff

What generation German?
 Would they feel more comfortable
speaking in German?


A consumer reacting to internal stimuli.

German Consumers
Suggestions from our Gillespie MHC staff in Fredericksburg

They may be resistant to seeking
mental services.
They may be reluctant to take medication.
They may “keep things within the family.”
They are concerned about the stigma.

German Consumers
They may feel it’s a character flaw or a
disgrace.
 They are very concerned about
confidentiality.
 Drinking alcohol is an accepted part of
their culture.
 Teen drinking may be acceptable in their
family.


Hispanic Consumers
from the U.S. Census, 1/23/03 Houston Chronicle

Hispanics are the largest minority group in
the U.S. with 37 million people.
 Texas is approximately 32 percent
Hispanic
 11.5 % African American,
 3.3% Other
 53.1% Anglo


Treatment Issues for Hispanic
Consumers
Do we need an interpreter?
 Is the person Tejano or from Mexico?
What generation Hispanic?
Is the person using a curandero?

Treatment issues for Hispanic
Consumers
Hallucinations are natural in their
religion.
 Hearing the voice of a loved one or having
hallucinations might be an expectations
when celebrating the Day of the Dead.
 Hispanic families are patriarchal.


Hispanic Consumers and
The Day of the Dead
A man is dressed in a skeleton
costume to portray death
in a celebration of
Dia de los Muertos,
The Day of the Dead.
People visit the graves of their
dead relatives to honor them.

Native Americans

Treatment Issues for Native
American Consumers
 Impact of racism,unemployment,and poverty.
 Coping with reservation life and
assimilation in mainstream culture.
 Consider the obesity, diabetes,
hypertension, and alcoholism in adults
and fetal alcohol syndrome in children.
 High use of native healers in the Southwest.

African Americans

African Americans
from the Houston Chronicle, 1/23/03

There are 36.2 million Americans who
identify themselves as “black only.”
 37.7 million identify themselves as “black
and at least one other race.”
 11.5% of Texans are African Americans.


Treatment Issues for African
American
Assess for co-occurring substance use
disorders and alcoholism.
 Address complications of obesity,
hypertension, diabetes,congestive heart
failure, asthma, and cancer.
 Sickle cell anemia is another illness
specific to African Americans.


Treatment Issues for African
Americans
Matriarchy; Mom or grandmother are the
dominant family figures.
 Lack of male role models and intact
families.
 Extended family or the Church may be
supports.


Treatment Issues for African
Americans


There is discrimination within their own
group based on skin color, hair texture,
class, values, etc.

Treatment Issues for Asians

Asians rarely seek help until its very severe.
Asians have extremely low admissions to state hospitals.
Mental illness is considered shameful. It’s hidden.
Is an interpreter needed?

Treatment Issues for Asians
Focus on physical symptoms.
 Asians are sensitive to medication.
 Give ½ the standard dose.
 Asians may use traditional healers and
herbal medicine.
 Asians may “flush” when drinking
alcohol.


Asian Consumers

Acupuncture has been used to treat
pain, schizophrenia, depression, and addictions.

Treatment Issues for Asians
Asian Cultures are patriarchal.
 The males in the family have the authority.
 Asians are more formal and inhibited in
their social behavior.


Older Adults

Treatment Issues for Older
Adults
Are they aware they need help?

Treatment Issues for Older
Adults
Is their mental illness caused by medicine?
 Do their medical problems cause or
complicate their mental illness?
 Is there Elder Abuse?


Gay Men and Lesbian Women
May struggle with homophobia and“being in the
closet” at work and with their families.
Gay people may want marriage, children, partner
benefits, etc., but may endure legal barriers.

Gay and Lesbian Women
Gay people often have specific health
issues related to their sexual practices.
 HIV, AIDS and STD’s are still concerns
with Gay men.
 People may be grieving the death of a
partner or friends who’ve died from AIDS,
or coping with living with AIDS or being
HIV+ themselves.


Treatment Issues for Gay and
Lesbians
Explore childhood abuse issues and
Domestic Violence..
 Assess for substance use and alcoholism.
 Sex enhancing drug use may be common
among some gay men.


Physically Challenged
Can they get to treatment?
Deal with their frustration and depression
Re: their disability.
 Do they need vocational assistance?

Mentally Challenged

Treatment Issues of Mentally
Challenged
They need to have meaningful activity
and purpose in their lives.
 They need to feel acknowledged and
appreciated.
 They need safety, structure, and security.
 Lack of continuity can cause crisis!
 They may need vocational assistance.


Winona Ryder

December 12, 2001,
Winona Ryder shoplifted
$5,560.40 designer items
from Saks Fifth Avenue in
Beverley Hills.

Twice an Academy
Award Nominated
actress

She had the following 8 drugs in
her possession:
Liquid demerol
 Liquid Diazepam
 Vicodin
 Percodan
 Valium
 Morphine sulfate
 Endocet (containing Oxycodone)


Patterns of Drug Use are highly
Regional.
 Drugs,

routes of administration, street
names, patterns of use, and drug
combinations may differ greatly, not
only between individuals from
different cultures, but different parts
of the country or even different parts
of the city.

Drugs of Choice
Native Americans-alcohol
 Asians-gambling, work
 Gay Men-stimulants, amyl nitrate, ecstasy
 “Rich”-prescription drugs, Internet porn
 M.D.’s –Vicodin


Drugs of Choice
Young adults-marijuana, cigarettes
 Geriatrics-alcohol, pills
 Sex Workers-crack cocaine, IV speedballs
 Screen mentally retarded for abuse too!


How Do We Best Serve Our
Consumers?




Examine own stereotypes.
Build trust.
Use People First language!

How do we best serve our
consumers?
Pronounce the person’s name correctly.
 Get an interpreter, if necessary.
 Educate yourself from the consumer, his
family, co-workers, etc.
 Remember differences do matter!



Slide 71

Cultural Competence
Integrating Differences
into Community Services

Objectives
Understand Stigma.
 Understand Culture Competency.
 Learn Culturally competent care for
people with Mental Health, Mental
Retardation and Addictions.


We live in an world
which often separates us.
Racism
 Sexism
 Ageism
 Feminism
 Classism
 Atheism


“Different” people are
“Stigmatized”

Mentally retarded inmates in a sanitorium in Germany

Stigma
Definitions from the U. of Chicago PSR Training Manual

“Stigmas are negative attitudes about a
group that lead to depriving them of
some fair opportunities.”

Stigma is related to…..
Stereotypes
Prejudice
Discrimination

Stereotypes
from The Asian Health Coalition of Illinois

Stereotypes are exaggerated beliefs
or fixed ideas about a person or
group which is held by people and
sustained by selective perception and
selective forgetting.

Prejudice
from The Asian Health Coalition of Illinois

Prejudice is a preconceived idea or
negative attitude formed before the
facts are known and sustained over
generalizations. A bias without
reason, resisting all evidence…

Discrimination
from The Asian Health Coalition of Illinois

Discrimination refers to treatment in
favor or against a person based on
the group to which that person
belongs and not on merit.

Stigmatized People…..
Experience being stereotyped and
are often the object of
discrimination and prejudice.

People are often stigmatized by:













Mental Illness
Mental Retardation
Physical Disability (including blindness, deafness)
Alcoholism /and or Drug Addiction
HIV or AIDS, Cancer or other terminal illnesses
Criminal behavior
Poverty
Alternative Lifestyles/sexual orientation
Wheelchair bound
Gender
Obesity

All our Consumers belong to
stigmatized groups!

Stigmatized People
Consumers and their families
can’t navigate the bureaucracy
even if resources are there.
It’s too frustrating!

Use People First Language
“I am more than my
illness….Don’t call me
“the schizophrenic,
“the addict” or
“the retard.”

As human beings, we have many
similarities…..
But, who we really are, is often
derived from our original family of origin
and our current lifestyle.

The Bottom Line:
People are different, even within
their own culture!
These differences matter when
planning and providing services.

National Mental Health
Association
“For Mental Health consumers, both
access to the services and the effectiveness
of the care they receive are greatly affected
by the degree to which the delivery system
is“culturally competent.”

Some important definitions
Related to Cultural Competency

Culture

from King,et. al

The Office of Special Programs, U.S. Dept. of Education

“The integrated patterns of human
behavior that includes thoughts,
communications, actions, customs,
beliefs,values, and institutions of
racial, ethnic, religious, or social
groups.”

Cultural Sensitivity
An awareness and respect of a
person’s cultural beliefs and
values.
Culhane-Pera, et .al

Cultural Competency
 Skills

(that translate into)
 Behaviors, Practices, Attitudes, and
 Policies
That enable an individual, agency, or
system to effectively serve culturally
diverse communities.
from The Asian Health Coalition of Illinois

Here at Hill Country MHDDC
Consumers are very diverse in their
language and culture.

61% of our Consumers are
Caucasian Americans
Many have German
backgrounds.

Our Consumers are …..

n
1% NativeAmerican

33% Hispanic
1% Asian

3% African
American

1% are “Others”

Consumers Have Many
Different Lifestyles

Lifestyles

They have many different
beliefs.

Can We Communicate?
Think Language first!
 Do we need an interpreter?
 Communicate respectfully.
 Be sensitive to the consumer and the family.
 Consider your dress, tone of voice, eye contact,
location, seating arrangement, privacy, etc.


Is our approach culturally
appropriate?
“What do you call your problem?”
“What name does it have?”
“What do you think caused your problem?”
“Why do you think it started when it did?”
From Arthur Kleinman’s question protocol in“Culture,Illness, and Care:
Clinical Lessons from Anthropologic and Cross Cultural Research”,
Ann.Intern.Med. 1978:Vol.88, pg.251-258

Important Issues to Consider…





Impact of religion.
How are women, men, elders, and children
treated in their culture?
Is there domestic violence?
Ethnic minorities generally underutilize
outpatient services, although African-Americans
are over-represented in inpatient setting.

Diagnosis






Minorities with Bipolar Disorder are often
diagnosed with schizophrenia. (Mukherjee,et al)
African Americans are over diagnosed with
schizophrenia and under diagnosed with mood
disorders. (Bell )
A mental health consumer’s addictions may not
be treated.
The elderly may not be assessed for substance
abuse or alcoholism.

Diagnosis
A person with a primary addiction problem
might not be treated for a co-occurring mental
illness.
 Learning disabilities may not be identified in
individuals with mental illness or substance
abuse.
 A person with mental retardation may not be
treated for mental illness or substance abuse.


Diagnosis
Post Traumatic Stress Disorder is often
undiagnosed in people suffering from
Domestic Abuse or other trauma.
 Children who are witnessing or are
victims of domestic abuse or another
trauma, may be misdiagnosed with
Attention Deficit Hyperactivity Disorder.


Medication Differences





Asians and Hispanics need lower doses of antipsychotics.
African Americans use the same doses of antipsychotics, but lower doses of lithium.
The elderly need lower dosages of medications.
Thus, metabolism of drugs varies with age and
ethnicity and is critical in prescribing
medications.

From “Making Room for Culture in Psychiatry” by Lin, et al.

Pain Tolerance
Men and women tolerate pain differently.
 Cultures tolerate pain differently.
 People with addictions develop a
hypersensitivity to pain.
 In certain cultures, self-inflicted pain is a
part of a religious experience.


Religion





Religious beliefs shape how the world is viewed.
Is illness a punishment? The devil’s work? An
evil spell? Bad karma?
For Hispanics, the curandero is a trusted healer.
For Lakota Sioux, the ritual Vision Quest,
praying and fasting at a holy site is life
changing.

Remember there are as many
differences
Between individuals in the same
culture as there are between
individuals in different cultures!

Two African American
families, one lesbian
and the other, multi-racial.

German Consumers
Suggestions from our Gillespie County MH staff

What generation German?
 Would they feel more comfortable
speaking in German?


A consumer reacting to internal stimuli.

German Consumers
Suggestions from our Gillespie MHC staff in Fredericksburg

They may be resistant to seeking
mental services.
They may be reluctant to take medication.
They may “keep things within the family.”
They are concerned about the stigma.

German Consumers
They may feel it’s a character flaw or a
disgrace.
 They are very concerned about
confidentiality.
 Drinking alcohol is an accepted part of
their culture.
 Teen drinking may be acceptable in their
family.


Hispanic Consumers
from the U.S. Census, 1/23/03 Houston Chronicle

Hispanics are the largest minority group in
the U.S. with 37 million people.
 Texas is approximately 32 percent
Hispanic
 11.5 % African American,
 3.3% Other
 53.1% Anglo


Treatment Issues for Hispanic
Consumers
Do we need an interpreter?
 Is the person Tejano or from Mexico?
What generation Hispanic?
Is the person using a curandero?

Treatment issues for Hispanic
Consumers
Hallucinations are natural in their
religion.
 Hearing the voice of a loved one or having
hallucinations might be an expectations
when celebrating the Day of the Dead.
 Hispanic families are patriarchal.


Hispanic Consumers and
The Day of the Dead
A man is dressed in a skeleton
costume to portray death
in a celebration of
Dia de los Muertos,
The Day of the Dead.
People visit the graves of their
dead relatives to honor them.

Native Americans

Treatment Issues for Native
American Consumers
 Impact of racism,unemployment,and poverty.
 Coping with reservation life and
assimilation in mainstream culture.
 Consider the obesity, diabetes,
hypertension, and alcoholism in adults
and fetal alcohol syndrome in children.
 High use of native healers in the Southwest.

African Americans

African Americans
from the Houston Chronicle, 1/23/03

There are 36.2 million Americans who
identify themselves as “black only.”
 37.7 million identify themselves as “black
and at least one other race.”
 11.5% of Texans are African Americans.


Treatment Issues for African
American
Assess for co-occurring substance use
disorders and alcoholism.
 Address complications of obesity,
hypertension, diabetes,congestive heart
failure, asthma, and cancer.
 Sickle cell anemia is another illness
specific to African Americans.


Treatment Issues for African
Americans
Matriarchy; Mom or grandmother are the
dominant family figures.
 Lack of male role models and intact
families.
 Extended family or the Church may be
supports.


Treatment Issues for African
Americans


There is discrimination within their own
group based on skin color, hair texture,
class, values, etc.

Treatment Issues for Asians

Asians rarely seek help until its very severe.
Asians have extremely low admissions to state hospitals.
Mental illness is considered shameful. It’s hidden.
Is an interpreter needed?

Treatment Issues for Asians
Focus on physical symptoms.
 Asians are sensitive to medication.
 Give ½ the standard dose.
 Asians may use traditional healers and
herbal medicine.
 Asians may “flush” when drinking
alcohol.


Asian Consumers

Acupuncture has been used to treat
pain, schizophrenia, depression, and addictions.

Treatment Issues for Asians
Asian Cultures are patriarchal.
 The males in the family have the authority.
 Asians are more formal and inhibited in
their social behavior.


Older Adults

Treatment Issues for Older
Adults
Are they aware they need help?

Treatment Issues for Older
Adults
Is their mental illness caused by medicine?
 Do their medical problems cause or
complicate their mental illness?
 Is there Elder Abuse?


Gay Men and Lesbian Women
May struggle with homophobia and“being in the
closet” at work and with their families.
Gay people may want marriage, children, partner
benefits, etc., but may endure legal barriers.

Gay and Lesbian Women
Gay people often have specific health
issues related to their sexual practices.
 HIV, AIDS and STD’s are still concerns
with Gay men.
 People may be grieving the death of a
partner or friends who’ve died from AIDS,
or coping with living with AIDS or being
HIV+ themselves.


Treatment Issues for Gay and
Lesbians
Explore childhood abuse issues and
Domestic Violence..
 Assess for substance use and alcoholism.
 Sex enhancing drug use may be common
among some gay men.


Physically Challenged
Can they get to treatment?
Deal with their frustration and depression
Re: their disability.
 Do they need vocational assistance?

Mentally Challenged

Treatment Issues of Mentally
Challenged
They need to have meaningful activity
and purpose in their lives.
 They need to feel acknowledged and
appreciated.
 They need safety, structure, and security.
 Lack of continuity can cause crisis!
 They may need vocational assistance.


Winona Ryder

December 12, 2001,
Winona Ryder shoplifted
$5,560.40 designer items
from Saks Fifth Avenue in
Beverley Hills.

Twice an Academy
Award Nominated
actress

She had the following 8 drugs in
her possession:
Liquid demerol
 Liquid Diazepam
 Vicodin
 Percodan
 Valium
 Morphine sulfate
 Endocet (containing Oxycodone)


Patterns of Drug Use are highly
Regional.
 Drugs,

routes of administration, street
names, patterns of use, and drug
combinations may differ greatly, not
only between individuals from
different cultures, but different parts
of the country or even different parts
of the city.

Drugs of Choice
Native Americans-alcohol
 Asians-gambling, work
 Gay Men-stimulants, amyl nitrate, ecstasy
 “Rich”-prescription drugs, Internet porn
 M.D.’s –Vicodin


Drugs of Choice
Young adults-marijuana, cigarettes
 Geriatrics-alcohol, pills
 Sex Workers-crack cocaine, IV speedballs
 Screen mentally retarded for abuse too!


How Do We Best Serve Our
Consumers?




Examine own stereotypes.
Build trust.
Use People First language!

How do we best serve our
consumers?
Pronounce the person’s name correctly.
 Get an interpreter, if necessary.
 Educate yourself from the consumer, his
family, co-workers, etc.
 Remember differences do matter!



Slide 72

Cultural Competence
Integrating Differences
into Community Services

Objectives
Understand Stigma.
 Understand Culture Competency.
 Learn Culturally competent care for
people with Mental Health, Mental
Retardation and Addictions.


We live in an world
which often separates us.
Racism
 Sexism
 Ageism
 Feminism
 Classism
 Atheism


“Different” people are
“Stigmatized”

Mentally retarded inmates in a sanitorium in Germany

Stigma
Definitions from the U. of Chicago PSR Training Manual

“Stigmas are negative attitudes about a
group that lead to depriving them of
some fair opportunities.”

Stigma is related to…..
Stereotypes
Prejudice
Discrimination

Stereotypes
from The Asian Health Coalition of Illinois

Stereotypes are exaggerated beliefs
or fixed ideas about a person or
group which is held by people and
sustained by selective perception and
selective forgetting.

Prejudice
from The Asian Health Coalition of Illinois

Prejudice is a preconceived idea or
negative attitude formed before the
facts are known and sustained over
generalizations. A bias without
reason, resisting all evidence…

Discrimination
from The Asian Health Coalition of Illinois

Discrimination refers to treatment in
favor or against a person based on
the group to which that person
belongs and not on merit.

Stigmatized People…..
Experience being stereotyped and
are often the object of
discrimination and prejudice.

People are often stigmatized by:













Mental Illness
Mental Retardation
Physical Disability (including blindness, deafness)
Alcoholism /and or Drug Addiction
HIV or AIDS, Cancer or other terminal illnesses
Criminal behavior
Poverty
Alternative Lifestyles/sexual orientation
Wheelchair bound
Gender
Obesity

All our Consumers belong to
stigmatized groups!

Stigmatized People
Consumers and their families
can’t navigate the bureaucracy
even if resources are there.
It’s too frustrating!

Use People First Language
“I am more than my
illness….Don’t call me
“the schizophrenic,
“the addict” or
“the retard.”

As human beings, we have many
similarities…..
But, who we really are, is often
derived from our original family of origin
and our current lifestyle.

The Bottom Line:
People are different, even within
their own culture!
These differences matter when
planning and providing services.

National Mental Health
Association
“For Mental Health consumers, both
access to the services and the effectiveness
of the care they receive are greatly affected
by the degree to which the delivery system
is“culturally competent.”

Some important definitions
Related to Cultural Competency

Culture

from King,et. al

The Office of Special Programs, U.S. Dept. of Education

“The integrated patterns of human
behavior that includes thoughts,
communications, actions, customs,
beliefs,values, and institutions of
racial, ethnic, religious, or social
groups.”

Cultural Sensitivity
An awareness and respect of a
person’s cultural beliefs and
values.
Culhane-Pera, et .al

Cultural Competency
 Skills

(that translate into)
 Behaviors, Practices, Attitudes, and
 Policies
That enable an individual, agency, or
system to effectively serve culturally
diverse communities.
from The Asian Health Coalition of Illinois

Here at Hill Country MHDDC
Consumers are very diverse in their
language and culture.

61% of our Consumers are
Caucasian Americans
Many have German
backgrounds.

Our Consumers are …..

n
1% NativeAmerican

33% Hispanic
1% Asian

3% African
American

1% are “Others”

Consumers Have Many
Different Lifestyles

Lifestyles

They have many different
beliefs.

Can We Communicate?
Think Language first!
 Do we need an interpreter?
 Communicate respectfully.
 Be sensitive to the consumer and the family.
 Consider your dress, tone of voice, eye contact,
location, seating arrangement, privacy, etc.


Is our approach culturally
appropriate?
“What do you call your problem?”
“What name does it have?”
“What do you think caused your problem?”
“Why do you think it started when it did?”
From Arthur Kleinman’s question protocol in“Culture,Illness, and Care:
Clinical Lessons from Anthropologic and Cross Cultural Research”,
Ann.Intern.Med. 1978:Vol.88, pg.251-258

Important Issues to Consider…





Impact of religion.
How are women, men, elders, and children
treated in their culture?
Is there domestic violence?
Ethnic minorities generally underutilize
outpatient services, although African-Americans
are over-represented in inpatient setting.

Diagnosis






Minorities with Bipolar Disorder are often
diagnosed with schizophrenia. (Mukherjee,et al)
African Americans are over diagnosed with
schizophrenia and under diagnosed with mood
disorders. (Bell )
A mental health consumer’s addictions may not
be treated.
The elderly may not be assessed for substance
abuse or alcoholism.

Diagnosis
A person with a primary addiction problem
might not be treated for a co-occurring mental
illness.
 Learning disabilities may not be identified in
individuals with mental illness or substance
abuse.
 A person with mental retardation may not be
treated for mental illness or substance abuse.


Diagnosis
Post Traumatic Stress Disorder is often
undiagnosed in people suffering from
Domestic Abuse or other trauma.
 Children who are witnessing or are
victims of domestic abuse or another
trauma, may be misdiagnosed with
Attention Deficit Hyperactivity Disorder.


Medication Differences





Asians and Hispanics need lower doses of antipsychotics.
African Americans use the same doses of antipsychotics, but lower doses of lithium.
The elderly need lower dosages of medications.
Thus, metabolism of drugs varies with age and
ethnicity and is critical in prescribing
medications.

From “Making Room for Culture in Psychiatry” by Lin, et al.

Pain Tolerance
Men and women tolerate pain differently.
 Cultures tolerate pain differently.
 People with addictions develop a
hypersensitivity to pain.
 In certain cultures, self-inflicted pain is a
part of a religious experience.


Religion





Religious beliefs shape how the world is viewed.
Is illness a punishment? The devil’s work? An
evil spell? Bad karma?
For Hispanics, the curandero is a trusted healer.
For Lakota Sioux, the ritual Vision Quest,
praying and fasting at a holy site is life
changing.

Remember there are as many
differences
Between individuals in the same
culture as there are between
individuals in different cultures!

Two African American
families, one lesbian
and the other, multi-racial.

German Consumers
Suggestions from our Gillespie County MH staff

What generation German?
 Would they feel more comfortable
speaking in German?


A consumer reacting to internal stimuli.

German Consumers
Suggestions from our Gillespie MHC staff in Fredericksburg

They may be resistant to seeking
mental services.
They may be reluctant to take medication.
They may “keep things within the family.”
They are concerned about the stigma.

German Consumers
They may feel it’s a character flaw or a
disgrace.
 They are very concerned about
confidentiality.
 Drinking alcohol is an accepted part of
their culture.
 Teen drinking may be acceptable in their
family.


Hispanic Consumers
from the U.S. Census, 1/23/03 Houston Chronicle

Hispanics are the largest minority group in
the U.S. with 37 million people.
 Texas is approximately 32 percent
Hispanic
 11.5 % African American,
 3.3% Other
 53.1% Anglo


Treatment Issues for Hispanic
Consumers
Do we need an interpreter?
 Is the person Tejano or from Mexico?
What generation Hispanic?
Is the person using a curandero?

Treatment issues for Hispanic
Consumers
Hallucinations are natural in their
religion.
 Hearing the voice of a loved one or having
hallucinations might be an expectations
when celebrating the Day of the Dead.
 Hispanic families are patriarchal.


Hispanic Consumers and
The Day of the Dead
A man is dressed in a skeleton
costume to portray death
in a celebration of
Dia de los Muertos,
The Day of the Dead.
People visit the graves of their
dead relatives to honor them.

Native Americans

Treatment Issues for Native
American Consumers
 Impact of racism,unemployment,and poverty.
 Coping with reservation life and
assimilation in mainstream culture.
 Consider the obesity, diabetes,
hypertension, and alcoholism in adults
and fetal alcohol syndrome in children.
 High use of native healers in the Southwest.

African Americans

African Americans
from the Houston Chronicle, 1/23/03

There are 36.2 million Americans who
identify themselves as “black only.”
 37.7 million identify themselves as “black
and at least one other race.”
 11.5% of Texans are African Americans.


Treatment Issues for African
American
Assess for co-occurring substance use
disorders and alcoholism.
 Address complications of obesity,
hypertension, diabetes,congestive heart
failure, asthma, and cancer.
 Sickle cell anemia is another illness
specific to African Americans.


Treatment Issues for African
Americans
Matriarchy; Mom or grandmother are the
dominant family figures.
 Lack of male role models and intact
families.
 Extended family or the Church may be
supports.


Treatment Issues for African
Americans


There is discrimination within their own
group based on skin color, hair texture,
class, values, etc.

Treatment Issues for Asians

Asians rarely seek help until its very severe.
Asians have extremely low admissions to state hospitals.
Mental illness is considered shameful. It’s hidden.
Is an interpreter needed?

Treatment Issues for Asians
Focus on physical symptoms.
 Asians are sensitive to medication.
 Give ½ the standard dose.
 Asians may use traditional healers and
herbal medicine.
 Asians may “flush” when drinking
alcohol.


Asian Consumers

Acupuncture has been used to treat
pain, schizophrenia, depression, and addictions.

Treatment Issues for Asians
Asian Cultures are patriarchal.
 The males in the family have the authority.
 Asians are more formal and inhibited in
their social behavior.


Older Adults

Treatment Issues for Older
Adults
Are they aware they need help?

Treatment Issues for Older
Adults
Is their mental illness caused by medicine?
 Do their medical problems cause or
complicate their mental illness?
 Is there Elder Abuse?


Gay Men and Lesbian Women
May struggle with homophobia and“being in the
closet” at work and with their families.
Gay people may want marriage, children, partner
benefits, etc., but may endure legal barriers.

Gay and Lesbian Women
Gay people often have specific health
issues related to their sexual practices.
 HIV, AIDS and STD’s are still concerns
with Gay men.
 People may be grieving the death of a
partner or friends who’ve died from AIDS,
or coping with living with AIDS or being
HIV+ themselves.


Treatment Issues for Gay and
Lesbians
Explore childhood abuse issues and
Domestic Violence..
 Assess for substance use and alcoholism.
 Sex enhancing drug use may be common
among some gay men.


Physically Challenged
Can they get to treatment?
Deal with their frustration and depression
Re: their disability.
 Do they need vocational assistance?

Mentally Challenged

Treatment Issues of Mentally
Challenged
They need to have meaningful activity
and purpose in their lives.
 They need to feel acknowledged and
appreciated.
 They need safety, structure, and security.
 Lack of continuity can cause crisis!
 They may need vocational assistance.


Winona Ryder

December 12, 2001,
Winona Ryder shoplifted
$5,560.40 designer items
from Saks Fifth Avenue in
Beverley Hills.

Twice an Academy
Award Nominated
actress

She had the following 8 drugs in
her possession:
Liquid demerol
 Liquid Diazepam
 Vicodin
 Percodan
 Valium
 Morphine sulfate
 Endocet (containing Oxycodone)


Patterns of Drug Use are highly
Regional.
 Drugs,

routes of administration, street
names, patterns of use, and drug
combinations may differ greatly, not
only between individuals from
different cultures, but different parts
of the country or even different parts
of the city.

Drugs of Choice
Native Americans-alcohol
 Asians-gambling, work
 Gay Men-stimulants, amyl nitrate, ecstasy
 “Rich”-prescription drugs, Internet porn
 M.D.’s –Vicodin


Drugs of Choice
Young adults-marijuana, cigarettes
 Geriatrics-alcohol, pills
 Sex Workers-crack cocaine, IV speedballs
 Screen mentally retarded for abuse too!


How Do We Best Serve Our
Consumers?




Examine own stereotypes.
Build trust.
Use People First language!

How do we best serve our
consumers?
Pronounce the person’s name correctly.
 Get an interpreter, if necessary.
 Educate yourself from the consumer, his
family, co-workers, etc.
 Remember differences do matter!



Slide 73

Cultural Competence
Integrating Differences
into Community Services

Objectives
Understand Stigma.
 Understand Culture Competency.
 Learn Culturally competent care for
people with Mental Health, Mental
Retardation and Addictions.


We live in an world
which often separates us.
Racism
 Sexism
 Ageism
 Feminism
 Classism
 Atheism


“Different” people are
“Stigmatized”

Mentally retarded inmates in a sanitorium in Germany

Stigma
Definitions from the U. of Chicago PSR Training Manual

“Stigmas are negative attitudes about a
group that lead to depriving them of
some fair opportunities.”

Stigma is related to…..
Stereotypes
Prejudice
Discrimination

Stereotypes
from The Asian Health Coalition of Illinois

Stereotypes are exaggerated beliefs
or fixed ideas about a person or
group which is held by people and
sustained by selective perception and
selective forgetting.

Prejudice
from The Asian Health Coalition of Illinois

Prejudice is a preconceived idea or
negative attitude formed before the
facts are known and sustained over
generalizations. A bias without
reason, resisting all evidence…

Discrimination
from The Asian Health Coalition of Illinois

Discrimination refers to treatment in
favor or against a person based on
the group to which that person
belongs and not on merit.

Stigmatized People…..
Experience being stereotyped and
are often the object of
discrimination and prejudice.

People are often stigmatized by:













Mental Illness
Mental Retardation
Physical Disability (including blindness, deafness)
Alcoholism /and or Drug Addiction
HIV or AIDS, Cancer or other terminal illnesses
Criminal behavior
Poverty
Alternative Lifestyles/sexual orientation
Wheelchair bound
Gender
Obesity

All our Consumers belong to
stigmatized groups!

Stigmatized People
Consumers and their families
can’t navigate the bureaucracy
even if resources are there.
It’s too frustrating!

Use People First Language
“I am more than my
illness….Don’t call me
“the schizophrenic,
“the addict” or
“the retard.”

As human beings, we have many
similarities…..
But, who we really are, is often
derived from our original family of origin
and our current lifestyle.

The Bottom Line:
People are different, even within
their own culture!
These differences matter when
planning and providing services.

National Mental Health
Association
“For Mental Health consumers, both
access to the services and the effectiveness
of the care they receive are greatly affected
by the degree to which the delivery system
is“culturally competent.”

Some important definitions
Related to Cultural Competency

Culture

from King,et. al

The Office of Special Programs, U.S. Dept. of Education

“The integrated patterns of human
behavior that includes thoughts,
communications, actions, customs,
beliefs,values, and institutions of
racial, ethnic, religious, or social
groups.”

Cultural Sensitivity
An awareness and respect of a
person’s cultural beliefs and
values.
Culhane-Pera, et .al

Cultural Competency
 Skills

(that translate into)
 Behaviors, Practices, Attitudes, and
 Policies
That enable an individual, agency, or
system to effectively serve culturally
diverse communities.
from The Asian Health Coalition of Illinois

Here at Hill Country MHDDC
Consumers are very diverse in their
language and culture.

61% of our Consumers are
Caucasian Americans
Many have German
backgrounds.

Our Consumers are …..

n
1% NativeAmerican

33% Hispanic
1% Asian

3% African
American

1% are “Others”

Consumers Have Many
Different Lifestyles

Lifestyles

They have many different
beliefs.

Can We Communicate?
Think Language first!
 Do we need an interpreter?
 Communicate respectfully.
 Be sensitive to the consumer and the family.
 Consider your dress, tone of voice, eye contact,
location, seating arrangement, privacy, etc.


Is our approach culturally
appropriate?
“What do you call your problem?”
“What name does it have?”
“What do you think caused your problem?”
“Why do you think it started when it did?”
From Arthur Kleinman’s question protocol in“Culture,Illness, and Care:
Clinical Lessons from Anthropologic and Cross Cultural Research”,
Ann.Intern.Med. 1978:Vol.88, pg.251-258

Important Issues to Consider…





Impact of religion.
How are women, men, elders, and children
treated in their culture?
Is there domestic violence?
Ethnic minorities generally underutilize
outpatient services, although African-Americans
are over-represented in inpatient setting.

Diagnosis






Minorities with Bipolar Disorder are often
diagnosed with schizophrenia. (Mukherjee,et al)
African Americans are over diagnosed with
schizophrenia and under diagnosed with mood
disorders. (Bell )
A mental health consumer’s addictions may not
be treated.
The elderly may not be assessed for substance
abuse or alcoholism.

Diagnosis
A person with a primary addiction problem
might not be treated for a co-occurring mental
illness.
 Learning disabilities may not be identified in
individuals with mental illness or substance
abuse.
 A person with mental retardation may not be
treated for mental illness or substance abuse.


Diagnosis
Post Traumatic Stress Disorder is often
undiagnosed in people suffering from
Domestic Abuse or other trauma.
 Children who are witnessing or are
victims of domestic abuse or another
trauma, may be misdiagnosed with
Attention Deficit Hyperactivity Disorder.


Medication Differences





Asians and Hispanics need lower doses of antipsychotics.
African Americans use the same doses of antipsychotics, but lower doses of lithium.
The elderly need lower dosages of medications.
Thus, metabolism of drugs varies with age and
ethnicity and is critical in prescribing
medications.

From “Making Room for Culture in Psychiatry” by Lin, et al.

Pain Tolerance
Men and women tolerate pain differently.
 Cultures tolerate pain differently.
 People with addictions develop a
hypersensitivity to pain.
 In certain cultures, self-inflicted pain is a
part of a religious experience.


Religion





Religious beliefs shape how the world is viewed.
Is illness a punishment? The devil’s work? An
evil spell? Bad karma?
For Hispanics, the curandero is a trusted healer.
For Lakota Sioux, the ritual Vision Quest,
praying and fasting at a holy site is life
changing.

Remember there are as many
differences
Between individuals in the same
culture as there are between
individuals in different cultures!

Two African American
families, one lesbian
and the other, multi-racial.

German Consumers
Suggestions from our Gillespie County MH staff

What generation German?
 Would they feel more comfortable
speaking in German?


A consumer reacting to internal stimuli.

German Consumers
Suggestions from our Gillespie MHC staff in Fredericksburg

They may be resistant to seeking
mental services.
They may be reluctant to take medication.
They may “keep things within the family.”
They are concerned about the stigma.

German Consumers
They may feel it’s a character flaw or a
disgrace.
 They are very concerned about
confidentiality.
 Drinking alcohol is an accepted part of
their culture.
 Teen drinking may be acceptable in their
family.


Hispanic Consumers
from the U.S. Census, 1/23/03 Houston Chronicle

Hispanics are the largest minority group in
the U.S. with 37 million people.
 Texas is approximately 32 percent
Hispanic
 11.5 % African American,
 3.3% Other
 53.1% Anglo


Treatment Issues for Hispanic
Consumers
Do we need an interpreter?
 Is the person Tejano or from Mexico?
What generation Hispanic?
Is the person using a curandero?

Treatment issues for Hispanic
Consumers
Hallucinations are natural in their
religion.
 Hearing the voice of a loved one or having
hallucinations might be an expectations
when celebrating the Day of the Dead.
 Hispanic families are patriarchal.


Hispanic Consumers and
The Day of the Dead
A man is dressed in a skeleton
costume to portray death
in a celebration of
Dia de los Muertos,
The Day of the Dead.
People visit the graves of their
dead relatives to honor them.

Native Americans

Treatment Issues for Native
American Consumers
 Impact of racism,unemployment,and poverty.
 Coping with reservation life and
assimilation in mainstream culture.
 Consider the obesity, diabetes,
hypertension, and alcoholism in adults
and fetal alcohol syndrome in children.
 High use of native healers in the Southwest.

African Americans

African Americans
from the Houston Chronicle, 1/23/03

There are 36.2 million Americans who
identify themselves as “black only.”
 37.7 million identify themselves as “black
and at least one other race.”
 11.5% of Texans are African Americans.


Treatment Issues for African
American
Assess for co-occurring substance use
disorders and alcoholism.
 Address complications of obesity,
hypertension, diabetes,congestive heart
failure, asthma, and cancer.
 Sickle cell anemia is another illness
specific to African Americans.


Treatment Issues for African
Americans
Matriarchy; Mom or grandmother are the
dominant family figures.
 Lack of male role models and intact
families.
 Extended family or the Church may be
supports.


Treatment Issues for African
Americans


There is discrimination within their own
group based on skin color, hair texture,
class, values, etc.

Treatment Issues for Asians

Asians rarely seek help until its very severe.
Asians have extremely low admissions to state hospitals.
Mental illness is considered shameful. It’s hidden.
Is an interpreter needed?

Treatment Issues for Asians
Focus on physical symptoms.
 Asians are sensitive to medication.
 Give ½ the standard dose.
 Asians may use traditional healers and
herbal medicine.
 Asians may “flush” when drinking
alcohol.


Asian Consumers

Acupuncture has been used to treat
pain, schizophrenia, depression, and addictions.

Treatment Issues for Asians
Asian Cultures are patriarchal.
 The males in the family have the authority.
 Asians are more formal and inhibited in
their social behavior.


Older Adults

Treatment Issues for Older
Adults
Are they aware they need help?

Treatment Issues for Older
Adults
Is their mental illness caused by medicine?
 Do their medical problems cause or
complicate their mental illness?
 Is there Elder Abuse?


Gay Men and Lesbian Women
May struggle with homophobia and“being in the
closet” at work and with their families.
Gay people may want marriage, children, partner
benefits, etc., but may endure legal barriers.

Gay and Lesbian Women
Gay people often have specific health
issues related to their sexual practices.
 HIV, AIDS and STD’s are still concerns
with Gay men.
 People may be grieving the death of a
partner or friends who’ve died from AIDS,
or coping with living with AIDS or being
HIV+ themselves.


Treatment Issues for Gay and
Lesbians
Explore childhood abuse issues and
Domestic Violence..
 Assess for substance use and alcoholism.
 Sex enhancing drug use may be common
among some gay men.


Physically Challenged
Can they get to treatment?
Deal with their frustration and depression
Re: their disability.
 Do they need vocational assistance?

Mentally Challenged

Treatment Issues of Mentally
Challenged
They need to have meaningful activity
and purpose in their lives.
 They need to feel acknowledged and
appreciated.
 They need safety, structure, and security.
 Lack of continuity can cause crisis!
 They may need vocational assistance.


Winona Ryder

December 12, 2001,
Winona Ryder shoplifted
$5,560.40 designer items
from Saks Fifth Avenue in
Beverley Hills.

Twice an Academy
Award Nominated
actress

She had the following 8 drugs in
her possession:
Liquid demerol
 Liquid Diazepam
 Vicodin
 Percodan
 Valium
 Morphine sulfate
 Endocet (containing Oxycodone)


Patterns of Drug Use are highly
Regional.
 Drugs,

routes of administration, street
names, patterns of use, and drug
combinations may differ greatly, not
only between individuals from
different cultures, but different parts
of the country or even different parts
of the city.

Drugs of Choice
Native Americans-alcohol
 Asians-gambling, work
 Gay Men-stimulants, amyl nitrate, ecstasy
 “Rich”-prescription drugs, Internet porn
 M.D.’s –Vicodin


Drugs of Choice
Young adults-marijuana, cigarettes
 Geriatrics-alcohol, pills
 Sex Workers-crack cocaine, IV speedballs
 Screen mentally retarded for abuse too!


How Do We Best Serve Our
Consumers?




Examine own stereotypes.
Build trust.
Use People First language!

How do we best serve our
consumers?
Pronounce the person’s name correctly.
 Get an interpreter, if necessary.
 Educate yourself from the consumer, his
family, co-workers, etc.
 Remember differences do matter!



Slide 74

Cultural Competence
Integrating Differences
into Community Services

Objectives
Understand Stigma.
 Understand Culture Competency.
 Learn Culturally competent care for
people with Mental Health, Mental
Retardation and Addictions.


We live in an world
which often separates us.
Racism
 Sexism
 Ageism
 Feminism
 Classism
 Atheism


“Different” people are
“Stigmatized”

Mentally retarded inmates in a sanitorium in Germany

Stigma
Definitions from the U. of Chicago PSR Training Manual

“Stigmas are negative attitudes about a
group that lead to depriving them of
some fair opportunities.”

Stigma is related to…..
Stereotypes
Prejudice
Discrimination

Stereotypes
from The Asian Health Coalition of Illinois

Stereotypes are exaggerated beliefs
or fixed ideas about a person or
group which is held by people and
sustained by selective perception and
selective forgetting.

Prejudice
from The Asian Health Coalition of Illinois

Prejudice is a preconceived idea or
negative attitude formed before the
facts are known and sustained over
generalizations. A bias without
reason, resisting all evidence…

Discrimination
from The Asian Health Coalition of Illinois

Discrimination refers to treatment in
favor or against a person based on
the group to which that person
belongs and not on merit.

Stigmatized People…..
Experience being stereotyped and
are often the object of
discrimination and prejudice.

People are often stigmatized by:













Mental Illness
Mental Retardation
Physical Disability (including blindness, deafness)
Alcoholism /and or Drug Addiction
HIV or AIDS, Cancer or other terminal illnesses
Criminal behavior
Poverty
Alternative Lifestyles/sexual orientation
Wheelchair bound
Gender
Obesity

All our Consumers belong to
stigmatized groups!

Stigmatized People
Consumers and their families
can’t navigate the bureaucracy
even if resources are there.
It’s too frustrating!

Use People First Language
“I am more than my
illness….Don’t call me
“the schizophrenic,
“the addict” or
“the retard.”

As human beings, we have many
similarities…..
But, who we really are, is often
derived from our original family of origin
and our current lifestyle.

The Bottom Line:
People are different, even within
their own culture!
These differences matter when
planning and providing services.

National Mental Health
Association
“For Mental Health consumers, both
access to the services and the effectiveness
of the care they receive are greatly affected
by the degree to which the delivery system
is“culturally competent.”

Some important definitions
Related to Cultural Competency

Culture

from King,et. al

The Office of Special Programs, U.S. Dept. of Education

“The integrated patterns of human
behavior that includes thoughts,
communications, actions, customs,
beliefs,values, and institutions of
racial, ethnic, religious, or social
groups.”

Cultural Sensitivity
An awareness and respect of a
person’s cultural beliefs and
values.
Culhane-Pera, et .al

Cultural Competency
 Skills

(that translate into)
 Behaviors, Practices, Attitudes, and
 Policies
That enable an individual, agency, or
system to effectively serve culturally
diverse communities.
from The Asian Health Coalition of Illinois

Here at Hill Country MHDDC
Consumers are very diverse in their
language and culture.

61% of our Consumers are
Caucasian Americans
Many have German
backgrounds.

Our Consumers are …..

n
1% NativeAmerican

33% Hispanic
1% Asian

3% African
American

1% are “Others”

Consumers Have Many
Different Lifestyles

Lifestyles

They have many different
beliefs.

Can We Communicate?
Think Language first!
 Do we need an interpreter?
 Communicate respectfully.
 Be sensitive to the consumer and the family.
 Consider your dress, tone of voice, eye contact,
location, seating arrangement, privacy, etc.


Is our approach culturally
appropriate?
“What do you call your problem?”
“What name does it have?”
“What do you think caused your problem?”
“Why do you think it started when it did?”
From Arthur Kleinman’s question protocol in“Culture,Illness, and Care:
Clinical Lessons from Anthropologic and Cross Cultural Research”,
Ann.Intern.Med. 1978:Vol.88, pg.251-258

Important Issues to Consider…





Impact of religion.
How are women, men, elders, and children
treated in their culture?
Is there domestic violence?
Ethnic minorities generally underutilize
outpatient services, although African-Americans
are over-represented in inpatient setting.

Diagnosis






Minorities with Bipolar Disorder are often
diagnosed with schizophrenia. (Mukherjee,et al)
African Americans are over diagnosed with
schizophrenia and under diagnosed with mood
disorders. (Bell )
A mental health consumer’s addictions may not
be treated.
The elderly may not be assessed for substance
abuse or alcoholism.

Diagnosis
A person with a primary addiction problem
might not be treated for a co-occurring mental
illness.
 Learning disabilities may not be identified in
individuals with mental illness or substance
abuse.
 A person with mental retardation may not be
treated for mental illness or substance abuse.


Diagnosis
Post Traumatic Stress Disorder is often
undiagnosed in people suffering from
Domestic Abuse or other trauma.
 Children who are witnessing or are
victims of domestic abuse or another
trauma, may be misdiagnosed with
Attention Deficit Hyperactivity Disorder.


Medication Differences





Asians and Hispanics need lower doses of antipsychotics.
African Americans use the same doses of antipsychotics, but lower doses of lithium.
The elderly need lower dosages of medications.
Thus, metabolism of drugs varies with age and
ethnicity and is critical in prescribing
medications.

From “Making Room for Culture in Psychiatry” by Lin, et al.

Pain Tolerance
Men and women tolerate pain differently.
 Cultures tolerate pain differently.
 People with addictions develop a
hypersensitivity to pain.
 In certain cultures, self-inflicted pain is a
part of a religious experience.


Religion





Religious beliefs shape how the world is viewed.
Is illness a punishment? The devil’s work? An
evil spell? Bad karma?
For Hispanics, the curandero is a trusted healer.
For Lakota Sioux, the ritual Vision Quest,
praying and fasting at a holy site is life
changing.

Remember there are as many
differences
Between individuals in the same
culture as there are between
individuals in different cultures!

Two African American
families, one lesbian
and the other, multi-racial.

German Consumers
Suggestions from our Gillespie County MH staff

What generation German?
 Would they feel more comfortable
speaking in German?


A consumer reacting to internal stimuli.

German Consumers
Suggestions from our Gillespie MHC staff in Fredericksburg

They may be resistant to seeking
mental services.
They may be reluctant to take medication.
They may “keep things within the family.”
They are concerned about the stigma.

German Consumers
They may feel it’s a character flaw or a
disgrace.
 They are very concerned about
confidentiality.
 Drinking alcohol is an accepted part of
their culture.
 Teen drinking may be acceptable in their
family.


Hispanic Consumers
from the U.S. Census, 1/23/03 Houston Chronicle

Hispanics are the largest minority group in
the U.S. with 37 million people.
 Texas is approximately 32 percent
Hispanic
 11.5 % African American,
 3.3% Other
 53.1% Anglo


Treatment Issues for Hispanic
Consumers
Do we need an interpreter?
 Is the person Tejano or from Mexico?
What generation Hispanic?
Is the person using a curandero?

Treatment issues for Hispanic
Consumers
Hallucinations are natural in their
religion.
 Hearing the voice of a loved one or having
hallucinations might be an expectations
when celebrating the Day of the Dead.
 Hispanic families are patriarchal.


Hispanic Consumers and
The Day of the Dead
A man is dressed in a skeleton
costume to portray death
in a celebration of
Dia de los Muertos,
The Day of the Dead.
People visit the graves of their
dead relatives to honor them.

Native Americans

Treatment Issues for Native
American Consumers
 Impact of racism,unemployment,and poverty.
 Coping with reservation life and
assimilation in mainstream culture.
 Consider the obesity, diabetes,
hypertension, and alcoholism in adults
and fetal alcohol syndrome in children.
 High use of native healers in the Southwest.

African Americans

African Americans
from the Houston Chronicle, 1/23/03

There are 36.2 million Americans who
identify themselves as “black only.”
 37.7 million identify themselves as “black
and at least one other race.”
 11.5% of Texans are African Americans.


Treatment Issues for African
American
Assess for co-occurring substance use
disorders and alcoholism.
 Address complications of obesity,
hypertension, diabetes,congestive heart
failure, asthma, and cancer.
 Sickle cell anemia is another illness
specific to African Americans.


Treatment Issues for African
Americans
Matriarchy; Mom or grandmother are the
dominant family figures.
 Lack of male role models and intact
families.
 Extended family or the Church may be
supports.


Treatment Issues for African
Americans


There is discrimination within their own
group based on skin color, hair texture,
class, values, etc.

Treatment Issues for Asians

Asians rarely seek help until its very severe.
Asians have extremely low admissions to state hospitals.
Mental illness is considered shameful. It’s hidden.
Is an interpreter needed?

Treatment Issues for Asians
Focus on physical symptoms.
 Asians are sensitive to medication.
 Give ½ the standard dose.
 Asians may use traditional healers and
herbal medicine.
 Asians may “flush” when drinking
alcohol.


Asian Consumers

Acupuncture has been used to treat
pain, schizophrenia, depression, and addictions.

Treatment Issues for Asians
Asian Cultures are patriarchal.
 The males in the family have the authority.
 Asians are more formal and inhibited in
their social behavior.


Older Adults

Treatment Issues for Older
Adults
Are they aware they need help?

Treatment Issues for Older
Adults
Is their mental illness caused by medicine?
 Do their medical problems cause or
complicate their mental illness?
 Is there Elder Abuse?


Gay Men and Lesbian Women
May struggle with homophobia and“being in the
closet” at work and with their families.
Gay people may want marriage, children, partner
benefits, etc., but may endure legal barriers.

Gay and Lesbian Women
Gay people often have specific health
issues related to their sexual practices.
 HIV, AIDS and STD’s are still concerns
with Gay men.
 People may be grieving the death of a
partner or friends who’ve died from AIDS,
or coping with living with AIDS or being
HIV+ themselves.


Treatment Issues for Gay and
Lesbians
Explore childhood abuse issues and
Domestic Violence..
 Assess for substance use and alcoholism.
 Sex enhancing drug use may be common
among some gay men.


Physically Challenged
Can they get to treatment?
Deal with their frustration and depression
Re: their disability.
 Do they need vocational assistance?

Mentally Challenged

Treatment Issues of Mentally
Challenged
They need to have meaningful activity
and purpose in their lives.
 They need to feel acknowledged and
appreciated.
 They need safety, structure, and security.
 Lack of continuity can cause crisis!
 They may need vocational assistance.


Winona Ryder

December 12, 2001,
Winona Ryder shoplifted
$5,560.40 designer items
from Saks Fifth Avenue in
Beverley Hills.

Twice an Academy
Award Nominated
actress

She had the following 8 drugs in
her possession:
Liquid demerol
 Liquid Diazepam
 Vicodin
 Percodan
 Valium
 Morphine sulfate
 Endocet (containing Oxycodone)


Patterns of Drug Use are highly
Regional.
 Drugs,

routes of administration, street
names, patterns of use, and drug
combinations may differ greatly, not
only between individuals from
different cultures, but different parts
of the country or even different parts
of the city.

Drugs of Choice
Native Americans-alcohol
 Asians-gambling, work
 Gay Men-stimulants, amyl nitrate, ecstasy
 “Rich”-prescription drugs, Internet porn
 M.D.’s –Vicodin


Drugs of Choice
Young adults-marijuana, cigarettes
 Geriatrics-alcohol, pills
 Sex Workers-crack cocaine, IV speedballs
 Screen mentally retarded for abuse too!


How Do We Best Serve Our
Consumers?




Examine own stereotypes.
Build trust.
Use People First language!

How do we best serve our
consumers?
Pronounce the person’s name correctly.
 Get an interpreter, if necessary.
 Educate yourself from the consumer, his
family, co-workers, etc.
 Remember differences do matter!
