Knowledge, Skills and Techniques in Working With Latino and Other Ethnic Clients Presented By: Manuel Medina, Ph.D. , LCSW Presented To: Northern Arizona Regional Behavioral Health Authority Flagstaff, Arizona October 9, 2014
Dec 17, 2015
Knowledge, Skills and Techniques in Working With Latino and Other
Ethnic Clients
Presented By: Manuel Medina, Ph.D. ,
LCSW
Presented To:
Northern Arizona Regional Behavioral
Health Authority
Flagstaff, Arizona
October 9, 2014
TRAINING NORMS
1. Be on time2. Be respectful 3. Phones on vibrate4. Take a risk5. Be intellectually honest6. Be supportive of others7. Use I statements8. Wait till the person speaking finishes their thought
United States Ancestry
Percent
Largest Ancestries
2000
US Census
US Percent of Religious Denomination Census 2000
WHO IS IN THE ROOM Please state your name The agency you work with How long you have been with them Your position or role Your ethnicity / ancestry Who you were name after or your family’s
practice for naming members of the family What is you expectation for today’s training
What Accounts for Success
Program Level
Client Outcomes
Generic Criteria for Assessing and Evaluating Programs
Availability: Are the services geographically available?
Accessibility: Handicap, language, hours, days, holidays,
Acceptability: Are the services acceptable to the clients, culturally appropriate
Appropriateness: Are the services of the kind that will make an impact with the
population it is designed to serve;
Efficiency: Are the services and being delivered in the most cost effective
manner
Effectiveness: Outcomes; Are the program’s services and efforts resulting in client improvement in their social roles and functioning
Program Logic Model
Given Ethnic Clients’ Needs What Resources
Will Produce Outcomes
• Acculturation Stress • Addictions• Alcohol drugs• Cope Strategies against discrimination and racism• Housing• Incomes / jobs• Interpersonal Skills • Mental Disorders• Resiliency• Self Advocacy
•Theirs•Yours•Ours
Functioning
• Reduce Regression in Functioning
•Maintain functional Level
•Improve Functional Level
How Much Effort is Required for Client Improvementsand How Responsive is The System
50% of Clients are measurably improved by the end of 8th session
75% by the end of 24 sessions (once a week) (Effectiveness of Psychotherapy: Lambert, M.J. & Bergin, A.E. Handbook of Psychotherapy and Behavior Change 4th Ed. Bergin & Garfield)
Outcomes: 52%-70% of Depressed clients had improved at one and two
years post treatment. One year after treatment 30% were sober and 30% had reduces
intake of alcohol (Psychotherapy: Lambert, M.J. & Bergin, A.E. Handbook of Psychotherapy and Behavior Change 4th Ed. Bergin & Garfield)
8%-20% of Clients will be worse off than when they started treatment (Dr. Christian Jarrett, the Psychologist Vol: 21 No. 1 January 2008)
49% failed to show for first session (2992 sample)41% of Clients failed to return after intake session (sample 2,551) At a certain agency that I am intimately familiar with our no
show rate is 40%
VARIABLE WHICH ACCOUNT FOR SUCCESSFUL OUTCOMES
40% client and extra therapeutic factors30% Therapeutic Relations15% Expectancy and placebo effects15% Techniques unique to specific
Lambert, M.J. (1992) Psychotherapy Outcomes Research: Implications for Integrative and Eclectic Therapist. In J.C. Norcross & M.J Goldfried (Eds) Handbook of Psychotherapy Integration pp94-129)
http://www.nrepp.samhsa.gov/Norcross.aspx Evidence-Based Therapy Relationships John C. Norcross, Ph.D., & Michael J. Lambert,
Ph.D.
1. The therapy relationship makes substantial and consistent contributions to patient success in all types of psychotherapy studied (for example, psychodynamic, humanistic, cognitive, behavioral, systemic).
2. The therapy relationship accounts for why clients improve (or fail to improve) as much as the particular treatment method.
3. Practice and treatment guidelines should address therapist qualities and behaviors that promote the therapy relationship.
4. Practitioners should routinely monitor patients’ responses to the therapy relationship and ongoing treatment. Such monitoring leads to increased opportunities to repair alliance ruptures, improve the relationship, modify technical strategies, and avoid premature termination (Lambert, 2010).
http://www.nrepp.samhsa.gov/Norcross.aspx Evidence-Based Therapy Relationships John C. Norcross, Ph.D., & Michael J. Lambert,
Ph.D.
5. Efforts to promulgate best practices or evidence-based practices (EBPs) without including the relationship are incomplete and potentially misleading.
6. The relationship acts in concert with treatment methods, patient characteristics, and practitioner qualities in determining effectiveness. A comprehensive understanding of effective (and ineffective) psychotherapy will consider all these determinants and their optimal combinations.
7. Adapting or tailoring the relationship to several patient characteristics (in addition to diagnosis) enhances effectiveness (as summarized in chapter 13)
What is Cultural Knowledge
Knowledge base for working with Latinos Individuals, Families and Community
1.Socio-Historical Knowledge
2.Cultural Values:
3. Acculturation / Assimilation
4.Cultural Identity
5.Trauma
6.Addictions
7.Mental Health
.
Socio-Historical Knowledge
Socio-historical Knowledge: “Racial caste in this land is more than twice as old as the nations itself. It began with the campaigns of displacement, killing, and subjugation of the native peoples by European Settles, and then expanded to the chattel of slavery of imported Africans. Because the roots of American prejudice and racism are some 250 yeas deeper than the bedrock of our constitutional ideals, it would be yet another from of hubris to believe that the legacy can be undone in a mere generation or two and the wounds healed”.
(Smelser, N.J., Wilson, W.J.,& Mitchell, F. (EDS) (2001) American Becoming: Racial Trends and their Consequences. Vol: 1. National Research Council; National Academy Press Washington, DC)
“The border crossed Us, we did not cross the border”
From: Acuña,R.F. (2014) Occupied American: A History of Chicanos (8th Ed)
Latino Socio-Psychological Knowledge
“The Border Crossed Us We did not Cross the Border”
Acuña’s Occupied America
Acculturation and Assimilation
Assimilation: Is the taking on the values and
behavioral of the other culture. For example moving from a competitive to a collaborative relational values and behavior or vice versa.
Acculturation: is the changes that result from continuous contact between two cultures and the effects it has on both cultures. It occurs at both the individual and the group level.
What is Cultural Specific Knowledge
Cultural competence - Having the capacity to function effectively as an individual
and an organization within the context of the cultural beliefs, behaviors and needs
presented by consumers and their communities
Cultural Adaptional SpheresDimensions Values Orientation
People to Nature
Mastery: our Challenge is to conquer and control Nature
Harmony: With Nature People and Nature co-exist
Subjugation: Life is determined by external Forces
People to People
Individualist: Autonomy and Self Sufficiency is Paramount
Collateral: Consult with family, friends, clan, etc. Interdependent
Lineal: Vertical leaders and followers. Authority is critical
Human Activity Modality
Doing: Being Active ad working hard is rewarded
Being In Becoming: Our purpose is life is to develop our inner selves
Being: It is enough to just be
Temporal Focus of Life
Future: The Present: Is Sacrificed for a better tomorrow
The Present:The moment is everything don’t worry about tomorrow
The Past: is important learn from history honor ancestors.
VALUE SPHERES
MIDDLE CLASS E/A
ASIANS AMERICAN
NATIVE AMERICAN
AFRICAN AMERICAN
HISPANIC AMERICAN
PEOPLE TO NATURE
MASTER OVER
HARMONY HARMONY HARMONY HARMONY
PEOPLE TO PEOPLE
INDIVIDUAL COLLARTEAL COLLATERAL COLLATERAL COLLATERAL
TIME ORIENTATION
FUTURE PAST / PRESENT
PRESENT PRESENT PAST PRESENT
MODE OF ACTIVITY
DOING DOING BEING IN BECOMING
DOING BEING IN BECOMING
NATURE OF SPECIES
GOOD AND BAD
GOOD GOOD GOOD AND BAD
GOOD
Values Preference Comparison for Euro-Americans and Ethnic Minorities
Respeto: Respect for the person, the other, Position of authority, and other life roles.
Dignidad: Conducting one self with dignity, genuineness, and the giving of respect to self and the others
Compadrazgo: Extended family and the support system and obligations that come with an interdependence of relationships
Confiansa: Trust of others to share and participate in the interdependence on each other towards a common value or norm
Compromiso: To commit oneself to someone or something, to give of oneself, one's skills, abilities, and loyalty
Responsabilidad: Responsibility, to one’s role, to one’s obligation in that role, to follow thorough on obligations to family and the group.
Value Preference Comparison for Middle Class Euro-American and Ethnic Minorities
RACIAL CULTURAL IDENTITY FORMULATION STAGES
STAGES OF IDENTITY
DELVELOPMENT MODEL
ATTITUDE TOWARDS SELF
ATTITUDES TOWARDS OTHER OF THE SAME GROUPS
ATTITUDES TON OTHERS OF DIFFERENT GROUPS
ATTITUDE TOWARDS DOMINANT GROUP
CONFORMITYConformity Group depreciation Discriminatory Group appreciation
DISSONANCE Dissonance Conflict between group depreciating and group appreciation
Conflict between dominant view of minorities
Conflict between group appreciation and depreciation
RESISTANCE& IMMERSION
Resistance e& immersion
Group appreciation Conflict between cultural ethnocentrism
Group depreciation
INTROSPECTION IntrospectionConcern with nature unequivocal appreciation
Concerns with ethnocentrism basis of judging others
Concerns with basis of group depreciation
INTEGRARTIVE AWARENESS
Integrative awareness
Group appreciation Group appreciation Selective appreciation
Relevant Variables Working with Latino Clients
Prevalence IdentityAssimilation / Acculturation Migration / ImmigrationTrauma
US born LatinoMajor Depression 14.4% 18.3%Alcohol Dep. 18% 14.2%Any Sub Abuse 29.3% 24.7%
Experiences of Trauma in Latina Children
Abused at a younger age
More likely to be abused by their fathers or other relatives
More likely to have siblings who were also abused
Reported higher levels of family conflict
Reported less maternal support.
Motivational Interviewing Principles Open Ended Questions: Asking the client to talk about
what is important to them rather than asking closed-ended questions about what is important to the health professional
Affirmations: Helping the client remind themselves of strengths and abilities that make change more possible.
Reflective Listening: Selectively calling attention to those parts of the clients experience that might be consistent with the change by demonstrating that the health professional is paying attention.
Summaries: Helping the Client notice their statement and experience that are consistent with change.
Small Group Exercise #1
Utilizing the criteria of Culture Values and Acculturation Stress
• Propose three questions that a Therapist could utilize to establish a therapeutic alliance with someone from a different cultural group
• Identity the ancestral origin group for the client and the therapist
• Which criteria did you use / selected to propose interview questions and why.
• State your three questions and present to the larger group
Selected Bibliography Alegria, M. Woo, M. (2009) Conceptual Issues in Latino Mental Health.
In F.A. Villarial et.al. (2009) Handbook of US Latino Psychology: Developmental and Community Based Perspectives. SAGE, LA, Calf.
Gerson, H. (2004) Malinchismo: Betraying one’s Own. In S. Singer & S.L. Kimble Eds. (2004) The cultural Complex: Contemporary Jungian Perspective on Psyche and Society. Routledge. NY. NY.
Gonzalez, N.A. Fabrett, F.C. & Knight, G. P. (2009) Acculturation, Enculturation, and the Psychosocial Adaptation of Latino Youth. In F.A. Villarial et.al. ( 2009) Handbook of US Latino Psychology: Developmental and Community Based Perspectives. SAGE, LA, Calf. Lambert, M.J. (2013) Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change 6th Ed. John Wiley & Sons, Inc Hoboken, NJ
Lambert, M.J. Ed. (2013) The Efficacy and Effectiveness of Psychotherapy. In M. J. Lambert. (2013) Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change 6th Ed. John Wiley & Sons, Inc Hoboken, NJ
Selected Bibliography Nava, Y. (200) It’s All in the Frijoles: 100 Famous Latinos Share Real-Life
Stories, Time- Tested Dichos, Favorite Folktales and Inspiring Words of Wisdom. Simon & Schuster. NY. NY.
Por Editorial Epoca S.A. de C.V. (2002) Refranes Y Dichos Mexicanos. Emperadores No. 185. Col. Portales. Mexico D.F. ([email protected])
Quintana, S.M. & Scull, N.C. (2009) Latino Ethnic Identity. In F.A. Villarreal et.al. ( 2009) Handbook of US Latino Psychology: Developmental and Community Based Perspectives. SAGE, LA, Calf.
Singer, S. & Kimbles, S.L. Eds. (2004) The cultural Complex: Contemporary Jungian Perspective on Psyche and Society. Routledge. NY. NY.
The Workgroup on Adapting Latino Services. (2008). Adaptation guidelines for serving Latino children and families affected by Trauma (1st ed.). San Diego, CA: Chadwick Center for Children and Families.
Umaña-Taylor, A.J. & Alfaro, G.P. (2009) Acculturative Stress and Adaptation. In F.A. Villarial et.al. ( 2009) Handbook of US Latino Psychology: Developmental and Community Based Perspectives. SAGE, LA, Calf.
Villarruel, F.A. Carlo, G. Grau, J.M. Azmitia, M. Cabreta, N.J. & Chahin, T.J.( 2009) Handbook of US Latino Psychology: Developmental and Community Based Perspectives. SAGE, LA, Calf.
Zoja, L. (2004) Trauma and Abuse: The Development of Cultural Complex in the History of Latin America. In S. Singer & S.L. Kimble Eds. (2004) The cultural Complex: Contemporary Jungian Perspective on Psyche and Society. Routledge. NY. NY.