Transcript Mental Health Issues in Work with Immigrants and Refugees Georgi Kroupin, MA,LP Center for International Health, St.

Mental Health Issues in Work with
Immigrants and Refugees
Georgi Kroupin, MA,LP
Center for International Health,
St. Paul, MN
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New Americans:
Understanding & Working With Their
Mental Health Needs
New Americans:
Ordinary people under extraordinary stress
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New Americans

Pull immigration
 Push immigration
 We mostly deal with the Push
immigrants/refugees who experience stress
on multiple levels
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People balancing loss and gain:
living through
Opportunities
 For many – basic safety and security
 For some (seniors, handicapped people,
women) more possibilities for independence
and self-sufficiency
 Freedom or communication/information
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People balancing loss and gain:
living through
Internal Losses (individual)

Loss of Ease of Communication
 Loss of Independence and Self-Sufficiency
 Loss of Security and Stability
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People balancing loss and gain:
living through
Environmental losses (individual)
Negative Response:

Feeling that life was useless
 Difficulty finding your niche in the future
 Acculturation difficulties
 Hopelessness about the future
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People balancing loss and gain:
living through
Opportunities
 Perspective of gain of material possessions
 Opportunities for learning
 Opportunities for cultural development for
those who were denied their culture
 Access to social services for those who need
assistance
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People balancing loss and gain:
living through
Environmental losses (individual)
 Loss of Material Possessions
 Loss of Value of Education and Professional
Experience
 Loss of Roots and Connection to Cultural and
Social Traditions
 Loss of Connection to Family and Friends
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People balancing loss and gain:
living through
Opportunities
 For those who were denied them, gain of
basic civil rights
 For those who were denied it - may be an
opportunity to find their cultural identity
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People balancing loss and gain:
living through
Internal Losses (individual)
Negative Response:
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Feeling powerless, unable to control or even predict
future
Lack of trust in the system
Isolation and Confusion
Overuse and Pressure
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People balancing loss and gain:
living through
Internal Losses (individual)
 Loss of Status
 Loss of Self-Esteem and Personal Identity
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People balancing loss and gain:
living through
Internal Losses (individual)
Negative Response:
 Drinking/Drugs/Gambling
 Family abuse
 Adultery
 Mental Health problems
 Physical illness
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Irreversible loss and hope for
the future

Many refugees have experienced irreversible
loss
 Many also show incredible resilience
 They may be able to learn how to live with
loss and still have hope
 We need to learn how to tolerate ambiguity
and deal with balancing both parts at once
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People balancing loss and gain:
living through
Refugee family with a sick child: Angry father
Mother
Father
Social worker
MD Pediatrician
Daughter 16
Occupational therapist
Daughter Son 6
2.5
Son 12
Nurse
Physical therapist
Interpreter
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From DSM-I to DSM-IIIR:
From symbols to signs
In Biomedicine diseases are largely
biological in nature
 Disease entities are empirical and
universal
 They are “discovered” and then
described in increasingly full terms

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From DSM-I to DSM-IIIR:
From symbols to signs
Pre-DSM period
 1840 – “idiocy and insanity”
 1880 – “mania, melancholia, monomania,
paresis, dementia, dipsomania and epilepsy”
 1917 – American Medico-psychological
Association: uniform statistics for hospitals.
Revised in 1934
 Revised by the Veterans Administration and
the Navy during and after WWII (W.
Menninger)
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From DSM-I to DSM-IIIR:
From symbols to signs

Mental Hospital Service of the American
Psychiatric Association published DSM-I
 The hallmark of DSM-I is the idea of
“reaction”
 Symptoms as symbolic statements of
underlying problems
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From DSM-I to DSM-IIIR:
From symbols to signs
1968 – DSM-II
 Stepped away from the idea of
psychobiosocial conceptions of mental
disorders and dropped the label of “reactive”
 Retained the idea that mental illnesses are
symbolic expressions of hidden psychological
realities

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From DSM-I to DSM-IIIR:
From symbols to signs

DSM-III and IIIR: from symbols to symptoms
 Atheoretical and descriptive
 Term “neurosis” dropped as concealing ethiological
explanations
 Intentional move away from psychological
understanding of mental disorders
 A clear step toward the exclusive use of biological
ethiological models
 Biological model was believed to be more scientific
and more mainstream in terms of medicine
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From DSM-I to DSM-IIIR:
From symbols to signs

DSM-IIIR: identification of symptoms is
transformed an interpretation of symbols of
distress into a reading of signs of disease
 Away from psychosociocultural context
 Biological discourse replaces an existential,
phenomenological one
 The afflicted are represented in a purely
biological discourse: Schizophrenic replaced
by a person with schizophrenia
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From DSM-I to DSM-IIIR:
From symbols to signs
Classifications of mental disorders
(DSM-IIIR, IV) reflect a momentum in a
cultural historic process
 Psychiatric classifications may be seen
as historical and semantic processes,
not “things”

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From DSM-I to DSM-IIIR
Gaines (1992)

In Northern Germanic (Protestant) tradition self is
“egocentric”
 It is the locus of action, thought and emotion
 Self is distinct, autonomous and capable of control
and it is a source and center of motivation
 Social and natural worlds are independent of self and
ideally are subject to the actions of self
 Individual is believed of literally making him or herself
 Individuation and personal development/growth are
central popular and professional issues
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From DSM-I to DSM-IIIR
Gaines (1992)
Centrality of notion of “self-control” in
the Germanic tradition (and DSM III+)
 Ideal self is the one of “self-mastery”
 “Out-of-control” states are seen as
“pathological”
 Treatment is designed to assist
regaining the ideal of control

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From DSM-I to DSM-IIIR
Gaines (1992)

The notion of self as responsible for (self)
control is a central concept guiding clinical
practice
 Clinicians interpret patients without this
(unconscious) motivation as “not trying”,
“unconcerned about their condition”, “not
taking care of themselves”, “not involved in
their own treatment” (lack of “agency”)
 It may result in problematic patient/provider
interactions
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From DSM-I to DSM-IIIR
Gaines (1992)
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Mediterranean self is “sociocentric”
Self concept incorporates other persons
Individual character is partially determined by
“related others” (family, “people”)
Self is dependent on the environment and is
not completely under self’s control
Self is a dependent social construct, not an
independent psychological one
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New Americans:
Building a working relationship
Establish rapport
 Acknowledge stress and loss
 Access strengths and opportunities
 Encourage their initiative

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Refugee Families balancing
challenges and opportunities:
adaptation
Refugee family with a deaf second wife
First wife/mother 55
Husband 65
IP: Second wife
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MD
Son 26
Son 22
Daughter Son 18
Daughter 16
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DHH Advocate
Child
protection
Police
Family
Therapist
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Cultural issues in providing care
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There are barriers in our work that are
related to cultural differences and there
are other obstacles that may look as such
We need to differentiate between the two
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Cultural issues in providing care
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We often need to accept our cultural
incompetence
We are more similar than different
Being different can be an advantage
We can use both similarities and
differences to learn, understand, build trust,
and help
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Cultural issues in providing care
Refugee family with a sick child: An accident
Mother
Father
Psychologist
Midwife
Son 7m.o.
Nurse
Physical therapist
Child Protection
Interpreter
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Balancing incompetence and
skill: collaboration
Aspects which are frequently cultural
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Explanatory models of problems
Manifestations of mental health problems
Communicating mental health problems
Understanding/accessing social and MH services
Communication and decision making patterns among
family-client/patient-helping professional
Cultural acceptability of solutions
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Balancing incompetence and
skill: collaboration
Assessment:
 Most of existing instruments are not
translated
 Issues with construct validity: many Western
concepts do not exist in other cultures
 Issues with other validity: mental health
problems are manifested differently in
different cultures
 There are major practical limitations: literacy,
educational level, etc.
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Balancing incompetence and
skill: collaboration
Barriers, which masquerade as cultural
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Communication problems on part of helping
professionals
Language barrier, poor use of interpreters
Frank disagreement of clients and their families
with professional recommendations
Common histories of trauma, loss, political or war
violence
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Language, Culture and
Psychopathology
Westermeyer & Janca (1997)
Language and Cultural issues in MH
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Denotation
 Connotation
 Equivalence in translated materials
 Specificity of terms
 Reporting threshold in relation to symptom severity
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Language, Culture and
Psychopathology
Westermeyer & Janca (1997)
Translation of mental health assessment
instruments

Translation by a team of bilingual persons
 Back translation by one or more persons not familiar
with the original version
 Analysis of the three versions
 A pilot study in the target population
 Reevaluation of the pilot study data
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Cultural issues in providing care
Refugee family with a sick child: An accident
Mother
Father
Psychologist
Midwife
Son 7m.o.
Nurse
Physical therapist
Child Protection
Interpreter
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Balancing incompetence and
skill: collaboration
Issues related to our culture
 Our cultural push to explain, understand
 Our cultural push to prepare, be in control
 Our difficulty to accept irreversible loss
 Our guilt reaction
 Our tendency to trust rules more than feelings
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Balancing incompetence and
skill: collaboration

Working with other cultures gives us an
opportunity to look at our culture
 Often we assume that we are “normal” and
they are “cultural”
 Understanding our own culture and working
with equally important
 The fact that our culture represents the
system may not mean it’s “normal”
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Balancing incompetence and
skill: collaboration
What do we do?
 Try to separate “cultural” issues from other
problems
– Use professional interpreters whenever possible
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Look at yourself and you will find both
differences and similarities
Use both similarities and differences to learn,
understand, connect, develop trust, and help
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New American Families and Social
Systems
Refugee family with a dying mother
Mother
Father
MD
Nurse
Son 48 Son 42 Son 40 .
Patient advocate
Nurse
Nurse
Psychologist
Chair of Ethics Committee
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Clinical strategies

Three most important components of
successful cross-cultural care:
– Rapport
– Rapport
– Rapport
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Clinical strategies
Effective ways of establishing rapport:
 Developing curiosity
 Deconstructing therapy
 Working with “resistance”
 Accessing non-verbal dimensions of your
encounter
 Accepting and utilizing your cultural
incompetence
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Applying clinical strategies
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We can be competent in other dimensions of our
encounter to compensate for incompetence in certain
dimensions (reality check, metacommunication)
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