Lessons in cultural competency at Spring MARRCH Conference
Professionals in the addiction treatment and counseling fields gathered in the secluded lake resort of Grand View Lodge in Nisswa, Minn. for the MARRCH 2016 Spring Conference. On Fri., April 22 a panel of mental health experts shared their experiences as minority practitioners and outlined racial, ethnic and cultural disparities and the need for individualized treatment plans among Hispanic/Latino, Hmong and Somali individuals.
Dr. Jonathan Lofgren, a professor at Minnesota Community Technical College, moderated the panel consisting of Dr. Sean Bruna, Melanie Heu, José Picón, and Yussuf Shafie. The panelists are chemical dependency treatment experts with experience in treating Hispanic, Hmong and Somali patients.
Several themes emerged as panelists discussed cultural barriers and practical successes to alcohol, drug, and mental health treatment in their respective cultures. Perhaps one of the most widespread challenges for minority clinicians to implement with clients is a strong practice of cultural humility – resisting the tendency to over-identify with clients based on shared culture alone. Often, despite cultural similarities between client and practitioner, one's personal life stories and life options vary drastically.
That is to say, just because a counselor shares a cultural background with a client – be it Hmong, Somali, Latino or otherwise – does not mean their own individual experience will match with the client's. As Melanie Heu noted, clinicians often enjoy certain privileges that clients do not.
"Sometimes as professionals we misunderstand what is happening," added Dr. John Bruna, medical anthropologist and panel member.
But culturally responsive treatment methods are beneficial, according to the panelists, especially when tailored to the individual. With a requisite dose of cultural humility, minority clinicians with non-western cultural backgrounds may be able to better identify with clients who share that culture. This connection can foster a rapport and understanding beyond that of culturally uneducated clinicians.
While each panelist elaborated on their experience within a particular culture during his or her own keynote presentation at the conference, this article is a recap of the topics covered in the panel occurring on Friday, April 22, 2016.
Photo courtesy of Alliance Wellness Center - http://www.alliancewellnesscenter.com/about_us.html
Yussuf Shafie, founder of Alliance Wellness Center LLC in Bloomington, discussed the need for greater awareness and understanding of mental health and chemical dependency treatment within the Somali population in Minn.
According to Shafie, the Somali culture discourages trauma discussion and lacks understanding of the complexity underlying many mental issues and dual diagnoses.
As in many other cultures, Somali men must “man up” and “act tough” in the presence of mental issues due to an “either/or” understanding of mental illness:
“In our community either you’re crazy or you’re not,” Shafie said. “It’s a very black-and-white thinking.”
When it comes to chemical dependence, oftentimes a dual diagnosis exists, and mood-altering substances become a way for the individual to cope with symptoms for lack of more effective skill sets. Shafie mitigates this at Alliance by educating families and elders in the community, so that the suffering individual can find help.
His outreach trickles down through leaders in the mosques to potential clients who need help. Community members can feel more comfortable bringing their issues to such leaders rather than seeking professional help.
“People often go to mosques now, and that is where they can get help. They can go to the mosque, talk to the leaders, the leaders talk to us, and we can help them,” Shafie said.
Additionally, there exists a common misunderstanding in Somali families that if an individual would simply stop drinking or drugging, then he or she would be fine. But according to Shafie, there is always an underlying issue at the root of substance abuse.
Further walls between potential clients and treatment in the Somali culture include language barriers and negative opinions regarding psychiatric medication. According to Shafie, there is no Somali word for PTSD, depression and other DSM V terms, and that can complicate diagnoses and treatments, as well as the patient’s understanding of those.
Medication compliance can be a stumbling block as well, since many Somalis tend to focus on the negative side effects, according to Shafie, and will discontinue use once symptoms dissipate instead of continuing the medication for the prescribed time frame.
Practitioners must be able to better educate the Somali community, starting with leaders and elders and continuing to the younger generation, about the facts of mental illness – particularly chemical dependence and dual diagnoses – in order to overcome the cultural barriers surrounding a community that suffers as much as any from mental health issues.
Shafie and Alliance Wellness Center are taking every step possible to ensure that individuals have access to resources they need, and means to apply them, through the mosques, community leaders and family education.
Alliance Wellness Center LLC is a DHS-licensed chemical dependency outpatient treatment center located in Bloomington, MN founded by Yussuf Shafie MSW, LGSW in 2015. Alliance serves a multiracial clientele specializing in Somali populations. More information is available at www.AllianceWellnessCenter.com.
Hispanic and Latino
Pictured below right. Photo courtesy of Western Washington University- http://www.wwu.edu/newfaculty/2014/photos.shtml#/newfaculty/2014/gallery.shtml/BrunaS.jpg
Pictured below left. Photo courtesy of CLUES- http://www.clues.org/wp_english/staff/jose-picon-m-a-ladc/
José Picón emphasized the importance of listening to clients and recognizing their individual stories as well as the specific culture surrounding a client’s country of origin in order to treat the all-too-prevalent traumas associated with strife back home and crossing the border.
Many Hispanic and Latino individuals experience trauma as a daily occurrence, particularly when they come from South American countries in the midst of civil war. The perils of crossing the border into the U.S. can be a hugely traumatic experience, too, Picón said.
Thus, for Picón, it is crucial to take the time to get to know a client and establish a trusting relationship before delving into trauma therapy. This trust, however, can be challenging to establish for many non-Spanish speaking professionals due to language barriers.
There isn’t necessarily an immediate rapport between Picón, a Puerto Rican, and his Hispanic/Latino clients. As Picón noted, “Hispanic” and “Latino” are blanket terms used predominantly in the U.S., and are unfamiliar to many members of the cultures they purport to represent.
South and Central American immigrants tend to identify with their country of origin rather than the region, and each country has its own distinct culture and traditions that can contrast nearby nations.
One thing it seems they do share, however – with each other and with the Somali culture Shafie described – is a reluctance to visit therapists or counselors because of the stigma associated with mental health issues.
“There’s this notion that going to the therapist or a counselor, it’s for crazy people,” Picón explained.
Moreover, Picón stated that many Hispanic/Latinos don’t fully understand the complexities of various mental health diagnoses.
As for families, Picón described a sort of familial breakdown when Hispanic/Latinos come to the United States. Coming from cultures with extremely strong family tie, Picón has noticed families becoming less united. Hispanic/Latino parents often have to work multiple jobs to support their families here and abroad, according to Picón, and that leaves little time for family interaction.
“That sense of family being united, it’s kind of dissipating here in the U.S.,” Picón said, “and that creates a lot of conflict.”
The level of conflict only increases when a family member struggles with substance abuse and legal repercussions that prevent him or her from working and providing for the family.
But Picón sees hope in a family program at CLUES known as Familias Unidas, or United Families, which establishes early intervention with substance abuse within families, along with a host of other issues from gang affiliation to mental health stigma.
“We talk about depression, trauma, teens…” Picón said. “When the family is more united, it's less likely that their children will start using alcohol or drugs, or join gangs.”
And in a clinical setting, Picón explained that it is important for professionals to look for creative ways to incorporate a client’s culture and ways of thinking into treatment formulas to establish personalized, culturally-relevant treatment plans.
Finally, it is always important to remember to view clients as people, with real feelings and emotions, that simply need human connection.
“Sometimes we forget that we are human beings,” Picón said. “Sometimes a hug and a touch can cure so many things, and we forget about those emotional and human characteristics that we possess.”
Dr. Sean Bruna, Ph.D., is a medical anthropologist and associate professor at Western Washington University with training in team science, inter/transdisciplinary research, comparative effectiveness research (CER), and community based participatory research (CBPR) in frontier, rural and urban settings. More information about his research and work available at www.seanbruna.com and https://chss.wwu.edu/anthropology/anthropology-department-faculty
José R. Picón, M.A., LADC is the manager of chemical health services at Comunidades Latinas Unidas en Servicio (CLUES). CLUES is a culturally relevant resource and service nonprofit organization based in Minneapolis and specializing in Latino families. More information is available at www.clues.org.
At Pangea Care, Clinical Director Melanie Heu applies proven therapy and treatment techniques through a culturally sensitive lens to reach clients of Hmong, Karen and Hispanic/Latinos.
Many first generation immigrants, according to Heu, have little or no experience in a classroom setting, so traditional treatment models can feel foreign and alienating to clients.
Therefore, prior to a client's participation in treatment, a clinician must educate him or her on how to participate in group therapy sessions – raising hands, taking turns, listening to peers, etc. – in order for such treatment models to function effectively. Even then, clients’ unfamiliarity with the format can cause them to withhold discussion, or say what they believe will appease the professional in the room, Heu said.
The formal classroom treatment setting has a separate set of pitfalls for second generation immigrant clients and younger. Providing these more acculturated clients with curricula translated into Hmong, while intended to help clients, actually complicated the treatment process because they typically do not read or write Hmong in school settings, or at all in some cases.
“It didn’t feel natural to them; [reading in Hmong] isn’t something we do,” Heu said. “When we go to school, we read in English…and so some of them don’t read or write Hmong.”
One solution Heu practices at Pangea Care is to allow clients to lead their own wellness narrative. For example, certain non-profit organizations, Heu said, provide plots of land for Hmong women to garden -- an activity that feels more natural for them.
“Hmong women will go out and garden together, and they’ll have discussions about how their day is going, how their week is going…” Heu said. “And it’s coming from a place that feels genuine for them.”
Dr. Bruna reinforced this point my emphasizing the notion of "extending [treatment practices] beyond the foundations of a clinical encounter."
"Sometimes just walking around and having a session...about histories within individuals in that context, in that place, is critical," Bruna added.
Treatment settings can also bring forth clients’ perspective of illness in the context of oppression, according to Heu. Many clients, for example, do not believe there is any illness to treat, given the absence of physical symptoms common with mental illness. Thus, clients will view themselves as being forced into a treatment setting by external systems that do not understand their culture, as they see it.
The oppression context echoes previously mentioned cultural misunderstanding of mental illness and chemical dependency. The family’s role, too, is strong in the Hmong culture and can have unintentional negative impact on a client’s treatment. Because family is so important, Heu emphasized, family members want to treat the issues themselves and keep them within the family before seeking external professional help.
“By the time a client comes to Pangea, the family has checked out.” Heu said. “They’re tired, angry, they’ve exhausted all their options, they’ve done everything they can do…They think the problem is with the client and they no longer want to come to family therapy.”
Some treatment methods, however, such as EMDR modified for cultural responsiveness, have been especially beneficial for refugees to work through trauma. It has been so successful, she said, because it allows clients to process trauma without reliving or talking about it.
“For a lot of immigrant refugees, it’s shameful talking about a lot of the bad things that happened,” Heu said.
Melanie Heu, MSW, LICSW, LADC works as clinical director at Pangea Care Behavioral Health Services. Pangea Care works with a variety of cultures, specializing in services for Hmong, Karen and Spanish-speaking populations. More information is available at www.PangeaCare.com.