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SSPC cultural and linguistic matching april 30


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Presented by Dr. Felicia Wong, Dr. Jacqueline Smith, Dr. Daniel Fallon and Dr. Farha Abbasi.

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SSPC cultural and linguistic matching april 30

  1. 1. Workshop Chair: Felicia Kuo Wong, Presenters: Jacqueline N. Smith, Daniel Fallon, Farha Abbasi. SSPC Annual Meeting, Montreal, Canada Friday, April 30, 2010.
  2. 2. <ul><li>We have no financial disclosures to make </li></ul><ul><li>Affiliations: </li></ul><ul><li>APA SAMHSA Minority Fellows: </li></ul><ul><li>Dr. Wong, Dr. Smith, Dr. Abbasi </li></ul><ul><li>Umass Medical School Department of Psychiatry: Dr. Wong, Dr. Fallon </li></ul><ul><li>University of North Carolina: Dr. Smith </li></ul><ul><li>Michigan State University: Dr. Abbasi </li></ul>
  3. 3. <ul><li>1. Identify the barriers that multicultural patients face when accessing psychiatric care, and recognize the strategies employed to reduce the barriers – such as matching language, ethnicity or cultural factors of patient to provider. </li></ul><ul><li>2. Appreciate the benefits and potential disadvantages that matching patient to provider can present. </li></ul><ul><li>3. Consider alternative strategies and solutions to providing culturally competent care to our multicultural patient population. </li></ul>
  4. 4. <ul><li>Ethnic minorities comprise approximately one third of the United States population, yet are underrepresented among people receiving mental health services . </li></ul>Source: US Census Bureau 2008
  5. 5. <ul><li>Disparities in the use of mental health services can be attributed to factors including language, culture-specific stigmas, religious barriers, and the subjective impression that the mental health system is hard to navigate and may not provide appropriate care for them. </li></ul>
  6. 6. <ul><li>Research indicates that matching clients from a minority group with clinicians from the same background may increase community mental health services utilization and reduce emergency room use.  </li></ul>Photo Source:
  7. 7. <ul><li>We will explore the strategy of cultural and linguistic matching using three scenarios: </li></ul><ul><li>1) An African-American resident will share her experience seeing African-American patients in her clinic. </li></ul><ul><li>2) A Hispanic resident will discuss his experience seeing Spanish speaking patients. </li></ul><ul><li>3) A Muslim resident will share her experience working with the Muslim population. </li></ul>
  8. 8. <ul><li>1. When a culture-matched patient/trainee dyad is found, will other differences be ignored? </li></ul><ul><li>2. Will this benefit or harm the patient? </li></ul><ul><li>3. What are the concerns regarding confidentiality when the community is small? </li></ul><ul><li>4. Will exposure to culturally diverse groups be limited for other trainees if only minority residents are expected to see minority patients?   </li></ul>
  9. 9. Jacqueline N. Smith, MD PGY 5, University of North Carolina at Chapel Hill
  10. 11. <ul><li>Objectives: </li></ul><ul><li>Review cases </li></ul><ul><li>Highlight pros & cons of matching trainees with patients based on culture/ethnicity </li></ul><ul><li>Discuss practical considerations if taking this approach </li></ul>
  11. 12. <ul><li>Case 1: </li></ul><ul><li>66yo African American (AA) female with previous diagnosis of MDD </li></ul><ul><li>Has moderate-severe depression based on BDI, functional impairment </li></ul><ul><li>Was referred by PCP for management as she’s had a “failed” trial of fluoxetine </li></ul><ul><li>Was assigned to me in part based on our shared race </li></ul>
  12. 13. <ul><li>Case 1, cont: </li></ul><ul><li>I made several mistakes: </li></ul><ul><li>After establishing rapport, I assumed she was being compliant based on our assumed familiarity </li></ul><ul><li>I didn’t ask about her religious background, so I didn’t explore it’s impact on her non-compliance </li></ul><ul><li>It took a significant amount of time to include her family in the treatment plan </li></ul>
  13. 14. <ul><li>Case 2: </li></ul><ul><li>26yo AAF with previous diagnosis of MDD, Anxiety do NOS </li></ul><ul><li>Was taking fluoxetine per her PCP </li></ul><ul><li>Had recently begun graduate school </li></ul><ul><li>Was referred by Student Health for medication management & psychodynamic therapy </li></ul><ul><li>She had requested an AA provider </li></ul>
  14. 15. <ul><li>Case 2, cont: </li></ul><ul><li>She had significant difficulty surrounding being the first AA in her graduate program </li></ul><ul><li>She suspected racism in her colleagues & professors </li></ul><ul><li>She came to view me as a friend or sister, not as her therapist </li></ul>
  15. 16. <ul><li>Case 2, cont: </li></ul><ul><li>I never explored her initial request for an AA provider </li></ul><ul><li>Familiarity & even our similarity in age hindered progress in the therapy as she attempted to establish a peer relationship & I struggled to maintain a neutral stance in evaluating her perceptions </li></ul><ul><li>My supervisor lacked comfort in dealing with cultural/racial identity issues </li></ul>
  16. 17. <ul><li>Case 3: </li></ul><ul><li>11yo AAM with no formal psychiatric diagnosis </li></ul><ul><li>Referred by staff at the homeless shelter </li></ul><ul><li>Staff is concerned about his poor academic performance & what they view as excessive discipline </li></ul>
  17. 18. <ul><li>Case 3, cont: </li></ul><ul><li>A larger difficulty for this child & his family was homelessness, not race </li></ul><ul><li>Though the family was matched to me based on race, because of the disparity in SES, they were still mistrustful for a variety of reasons </li></ul>
  18. 19. <ul><li>Avoid feeling complacent because of familiarity </li></ul><ul><li>Attempt to maintain neutrality </li></ul><ul><li>Culture is multi-faceted: explore/research what you don’t know </li></ul><ul><li>Be aware of your own biases/assumptions </li></ul><ul><li>Recognize that transference/counter-transference, medication compliance, etc will be effected by culture </li></ul>
  19. 20. Daniel Fallon, MD Child and Adolescent Psychiatry Fellow University of Massachusetts Medical School CULTURAL AND LINGUISTIC MATCHING: A SPANISH SPEAKING RESIDENT’S PERSPECTIVE
  20. 22. <ul><li>Case 1: </li></ul><ul><li>A 36 y/o Spanish speaking Puerto Rican female was admitted overnight to our inpatient unit </li></ul><ul><li>Diagnosis: Major Depression with psychotic features. </li></ul><ul><li>During admission the resident who admitted her using a translator gathered that the patient believed that the “devil had been targeting her” </li></ul>
  21. 23. <ul><li>Case 2: : </li></ul><ul><li>“ Mrs. Rodriguez” is a 44 y/o Hispanic female referred by her PCP for management of anxiety. </li></ul><ul><ul><li>“ Hola, mucho gusto yo soy el Dr. Fallon…” </li></ul></ul><ul><li>Case 3: </li></ul><ul><li>18 y/o patient from Puerto Rico… </li></ul><ul><ul><li>“ from what part of the Island are you from?” </li></ul></ul>
  22. 24. <ul><li>When I started residency, I was an outspoken advocate and motivated provider, but not at all “culturally competent” </li></ul><ul><li>Luckily, I have worked on my cultural competence through some cases as a “Linguistic – matched” provider </li></ul><ul><li>“ What language do you prefer?” “I speak both… I speak Spanglish” </li></ul><ul><li>What it has taken: a lot of humility and sincere curiosity </li></ul>
  23. 25. <ul><li>Matching providers and patient based on an assumption that on paper their cultures’ match, is not real. </li></ul><ul><li>Language however can be reasonably matched. </li></ul><ul><li>Language is something that can be taught. </li></ul><ul><li>Language can help bridge deficits in access and service delivery among minorities </li></ul>
  24. 26. <ul><li>Case 1: </li></ul><ul><li>18 y/o male with substance dependence and depression </li></ul><ul><ul><li>“ Cuentame de Uruguay” </li></ul></ul><ul><li>Case 2: </li></ul><ul><li>“ Francine” was a 28 y/o female refugee from Cameroun admitted to our unit with severe PTSD </li></ul><ul><ul><li>In crisis or not, she often sought me out on the unit as we shared a bond through language </li></ul></ul>
  25. 27. <ul><li>Limitations exist, but in some cases like psychotherapy there may be a benefit to increase our overall linguistic repertoire </li></ul><ul><li>Language does not mean matching, but simply the sharing of a medium through which a patient and provider can learn from each other </li></ul>
  26. 28. <ul><li>What happens when a trainee is linguistically matched with a non-English speaking patient, and the supervisor doesn’t “talk the talk”? </li></ul><ul><li>Challenge of finding non-English psychotherapy resources </li></ul><ul><ul><li>“ Lista de distorciones cognitivas” </li></ul></ul><ul><ul><li>Dr. Lisa Fortuna – CBT supervisor </li></ul></ul><ul><li>Audiotaping of sessions to get feedback on what and how I communicate in the session. </li></ul>
  27. 29. <ul><li>It is not good to be “culturally matched” if you are not “culturally competent” </li></ul><ul><li>Is linguistic matching separate from, or part of, cultural matching? </li></ul><ul><li>What can be done so that trainees providing care in a different language can have access to training resources in that language? </li></ul>
  28. 30. FARHA ABBASI, MD Adult Psychiatry Resident University of Michigan “ HOW DO YOU DANCE WITH AN ELEPHANT?”: Cultural pairing of therapist and the patient
  29. 31. <ul><li>Play Farha’s Video here. </li></ul>
  30. 32. <ul><li>As a Chinese American, Mandarin speaking, resident who is identified by my residency program as a “culturally sensitive” provider – I get referrals to see any “minority” or non-English speaking patients at a much higher rate than my peers. </li></ul><ul><li>This places a burden on minority residents to see a disproportionate number of cases, and leaves others without the experience to practice “culturally competent psychiatry”. </li></ul>
  31. 33. 38 year old Chinese married, college educated, female (from Beijing) with paranoid schizophrenia was discharged from our inpatient unit June 2008. Referred to me for psychotherapy, June 2008-February 2009 (returned to China). At our last session, I asked her how she felt about our ethnic and language (Mandarin) matching. She said….
  32. 34. “ It guess it was easier that we could speak in Mandarin (she did speak some English), and I think it helped that you somewhat understand the Chinese culture, but if my doctor was nice, I would see him or her regardless of language, or race/ethnicity. That doesn’t matter to me. What matters to me and what helped me, is that you listened, and that you cared.”
  33. 35. <ul><li>1. When a culture-matched patient/trainee dyad is found, will other differences be ignored? </li></ul><ul><li>2. Will this benefit or harm the patient? </li></ul><ul><li>3. What are the concerns regarding confidentiality when the community is small? </li></ul><ul><li>4. Will exposure to culturally diverse groups be limited for other trainees if only minority residents are expected to see minority patients?   </li></ul>
  34. 36. <ul><li>5. Is it the decision to match the patient to a provider of the same language, race/ethnicity, gender, religion, culture… made by the patient, or by the treatment center/clinical providers? </li></ul><ul><li>6. What are some alternative strategies to address the disparity in mental health services utilization by minorities? </li></ul>
  35. 37. <ul><li>APA Minority Fellowship Program </li></ul><ul><li>Our residency training programs for supporting our efforts to raise awareness about this important topic. </li></ul><ul><li>Our families for their love and support </li></ul><ul><li>Our patients for teaching us these valuable lessons about the assumptions we make in treatment, and for helping us become better psychiatrists. </li></ul>
  36. 39. FARHA ABBASI, MD Adult Psychiatry Resident Michigan State University “ HOW DO YOU DANCE WITH AN ELEPHANT?”: Cultural pairing of therapist and the patient
  37. 40. <ul><li>She is an “ACCHHI LARKI”{good Girl}, hating every aspect of being one ,she projects all the anger on me, I represent a typical “ pakistani aunty”, we might be same yet very different from religious practices to political beliefs. </li></ul><ul><li>She is ferocious in her anger and I sometimes also feel that she takes a pleasure in putting me down. </li></ul><ul><li>I was never good enough, yet my offer to transfer to another resident was always turned down. </li></ul>
  38. 41. <ul><li>She helped me identify ,my cultural schemas and distortions, I too carry the heavy burden of living up to the image of Acchi larki everyday . Guilt is a bag of bricks that is put on our shoulders from a young age. </li></ul><ul><li>I in therapy provided her a safe place to vent the pent up anger and become less cynical. </li></ul><ul><li>She taught me it is easier to fight your weaknesses in others. </li></ul>
  39. 42. <ul><li>17 yr old female of Arab descent, covering her head. Sudden change in personality wants to date meet boys, dress up and not cover her head. </li></ul><ul><li>Sleep disturbances </li></ul><ul><li>Truancy, ran away with the family car, cops were called to get her back. </li></ul><ul><li>I assumed she is covering her head and comes from traditional family that she must be following strict Islamic code .Did not take a sexual or substance abuse history. </li></ul>
  40. 43. <ul><li>Once I took the cultural glasses off, I realized she is an average American teen ager who wants to live life her own way. </li></ul><ul><li>Goals of the therapy are what Patient wants to achieve, it might not be what you or the family presume is in best interest of the patient. </li></ul><ul><li>I understood the complexities ,sensibilities of the culture and learned to respect and work within that context. </li></ul>
  41. 44. <ul><li>An Iraqi refugee coming in for ECT treatment for severe recurrent depression . Multiple admissions for suicidal ideations .Patients chart showed him as Christian . No family was identified. Only support system was the local church. </li></ul><ul><li>His gestures ,use of certain words caught my attention, I walked upto him and greeted him in traditional Islamic tradition he replied back mindlessly but stopped mid sentence and requested I do not reveal his true identity to anyone. </li></ul>
  42. 45. <ul><li>Patient was an Iraqi soldier who killed his Iranian counterpart in the war. But became disillusioned by his faith .He converted and came to America through a church. His family back home does not know about it. He cannot go back or associate with any one from the community for fear of his life. </li></ul><ul><li>I was able to minimize his exaggerated fears and connect him back to his family and friends. Who were happy to know that he is alive and accepted him back. </li></ul>
  43. 47. <ul><li>So answer to the Question ,How do you dance with an elephant “VERY CAUTIOSLY AND SLOWLY” </li></ul><ul><li>Have the courage to ask him to dance, the strength to not run away, the insight to understand his temperament. The judgment for changing the music when the record would get stuck, have support for cheering on, to smile, through failures. keep it real, calm and endurable , learn the rhythm and to synchronize it. thank you all for dancing along with me and for a memorable musical. </li></ul>