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Assessment and Clinical Understanding of Accultura ...
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Hello and welcome. I am Jose Villagran, Clinical Director of Behavioral Health at Erie Family Health Centers and Community Care Expert for SMI Advisor. I am pleased that you are joining us for today's SMI Advisor webinar, Assessment and Clinical Understanding of Occulturative Stress and Severe Mental Illness Within the Latino Community. SMI Advisor, also known as the Clinical Support System for Serious Mental Illness, is an APA and SAMHSA initiative devoted to helping clinicians implement evidence-based care for those living with serious mental illness. Working with experts from across the SMI criminal community, our efforts have been designated to help you get the answers you need for the care of our patients. Today's webinar has been designated for one AMA PRA Category 1 credit for Physicians, one Continuing Education credit for Psychologists, and one Continuing Education credit for Social Workers. Credits for participating in today's webinar will be available until October 11th of 2022. Slides from today's presentation are available in the handout area, found in the lower portion of your control panel. Select the link to download the PDF. Please feel free to submit your questions throughout the presentation by typing them in the question line, also found in the lower portion of your control panel. We'll reserve 10-15 minutes at the end of the presentation for some Q&A. Next slide. Now, I would like to introduce you to today's faculty webinar host, Dr. Edgar Ramos. Dr. Edgar Ramos is a licensed clinical psychologist with over 17 years of varied clinical experience. Dr. Ramos has extensive experience working with children, adolescents, and adults. He has worked in various residential settings, behavioral health hospitals, nursing homes, and community mental health centers throughout Chicago. In addition, Dr. Ramos is the Assistant Dean at Concordia University in the Health, Science, and Technology Department. His primary focus is teaching in the Psychology Department. Dr. Ramos supervises and trains masters and doctor-level students at several sites. He is fluent in Spanish and provides clinical care in both Spanish and English. Dr. Ramos is an expert in adolescent gangs and has presented extensively on this topic. Dr. Ramos, thank you so much for leading today's webinar, and the floor is yours. Thank you, Jose. I appreciate that. So, we'll begin with disclosures. No relationships or conflicts of interest related to the subject matter of this presentation exist. And our learning objectives for today. Upon completion of this activity, participants will be able to, one, critically review and analyze acculturated stress and its impact on mental health within the Latinx community, assess acculturated stress symptoms, and apply them to culturally sensitive diagnoses, differentiate the clinical presentations of highly acculturated versus low-acculturated Latinx individuals to develop treatment plans, and finally, differentiate between acculturated stress and severe mental illness. So, before I begin and talk fully about acculturation, the approach to this presentation today will be really one, it's informational and it's the beginning or an introduction to acculturated stress and severe mental illness. And the reason for that is just so we all have the same language and same base for understanding acculturated stress. And the way I go about generally doing that is first defining to make sure we're on the same page with terms and whatnot, and giving a brief historical. Obviously, given today's time constraint within an hour that we have, I can't go into every theoretical formulation of acculturation or every definition that exists on acculturation or acculturated stress. So, I'm hitting on some that I find important for today's discussion. Acculturation is not something recent. In fact, it's been around as far back as 2370 BC. The ancient Sumerian rulers of Mesopotamia established written codes of law in order to protect traditional cultural practices from acculturative change and to establish fixed rules for commerce with foreigners. The word actual acculturation, according to the Oxford English Dictionary, was first used in English text 1880 by J. W. Powell to describe changes in Native American languages. So, the term and idea of acculturation has a long history. Obviously, the process in of itself has existed since the species walked this earth, but actual information or written, the written word of it has, does go back far within our history. So, one of the first things we're going to look at is Gordon's definition of acculturation or the model in which he established that it was a unidirectional and unidimensional. Immigrants were situated along a continuum between maintaining their cultural origin and adopting the host country's culture. The implicit definition of acculturation was that individuals would relinquish the values of their culture of origin and assimilate those of the host culture. That leads to the idea then of assimilation. And assimilation is the cultural absorption of a minority group into the main cultural body. And the way we tend to look at it, the way it's a good kind of metaphor for it is, years ago, we used to look at the assimilative process and the goal for individuals was to assimilate into the culture. And it used to be referred to, for those of you that maybe within my age range, we used to look at it as the melting pot in which everything kind of blended together and, you know, in the form of one shared pot. That's kind of like a no-no now, a little bit of a dirty word to say assimilation. So, we moved into the idea of acculturation, which metaphorically we looked at it as the salad bowl in which, you know, you have, you know, your croutons, you have your lettuce. If you're like me, you love bacon, you have bacon bits involved in it. And you can smother it all with the salad dressing of your choice, but yet every individual part still retains the integrity in context of its own flavor. So, that's conceptually a way of how you can look at acculturation is that while we transfer over, we still retain our portions of our identity, our important flavors to say. Another word that kind of pops up where people sometimes integrate it or try to use them interchangeably is inculturation. While the terms acculturation and or assimilation have been referred to one's orientation to the host culture, the term acculturation can be used to describe one's orientation to the culture of origin. Essentially is that ideas such as Latinoism become involved in that idea. In other words, we get kind of engulfed or encapsulated within our own cultural view, our own cultural identity, our own cultural ideas. So, currently we have several acculturation theory models. Barry seems to be one of the most prolific writers on acculturation and probably one of the most, arguably one of the most respected and utilized of acculturation models. So, I'm going to talk a little bit about Barry's model. He offered a bidirectional model with two attitudinal dimensions, maintenance of the original cultural identity and desire to have contact and participate in the host culture. The combinations of those two ideas and dimensions yield for acculturated patterns, namely four particular subsets, integration, assimilation, separation, and marginalization, which as we go into assessment, you'll see why integration, assimilation, separation, and marginalization become important. Acculturation, when he's talking about bidirectional, it's interesting because it would, for lack of a better word, what it means is that both cultural groups are adapting, acculturating to each other, meaning that not only does the immigrating group come to the host country and adapt some of the host country's features, traditions, values, beliefs, but the host country also adapts and receives some of the identity of that. And one of the examples that I give is years ago, salsa surpassed the use as one of the most major condiments used in the United States, surpassing that of ketchup. So, that's an example of how acculturation works in a bidirectional model, meaning that it goes both ways, is that both cultural groups are adapting and learning from each other. So, the strive and the goal is for a more acculturated process. On the basis of his model, others have developed an interactive model that incorporates the societal perspectives of immigrants. Acculturation patterns depend on the immigrant's ethno-cultural background, as well as in the demographic, socioeconomic, and political circumstances of the host culture. This model prioritizes an individual approach over a group affiliation. Now, these are the differences that can occur for the reasons why one is traveling or immigrating to the host culture, whether it be for political asylum or whatnot. In the early 90s, others developed acculturation as a complex process that is not linear, meaning that it doesn't move in a straight pattern. It's much more dynamic, fluid. It kind of goes in different directions. It can go backward. It can go forward. She proposed an ecological system model because acculturation strategies or patterns vary as a function of context, home, school, work, and a socialization process. And a way to kind of understand that is looking at how one adapts in the school system, learns the language, learns the societal norms or rules within a school context can be very different. And we've often heard that, I can say as a Latino myself, one of the things that I remember is growing up is having my parents say, you know, at home you speak Spanish. You're not going to learn English at home. Go to school and that's where you learn English. So that's the idea of how systemic or ecological process can occur within different functions or contexts. This model expanded on various ideas and includes seven acculturated strategies. Assimilation, separation, marginalization, blended biculturalism, integrated biculturalism, instrumental biculturalism, and identity exploration. By the late 90s, models were further continued. And the psychosocial model combined the four acculturated strategies initially described by Berry, integration, assimilation, separation, and marginalization, and the interactive nature of Burris' model. It holds that the acculturated process is influenced by the attitudes and strategies of the immigrant population and those of the host society. A primary contribution was that the introduction of psychosocial variables may predict acculturated patterns, such as expected outcome, in-group bias, and group similarity. Through the process of acculturation, what we experienced or a result of the acculturated process is the term acculturated stress, which is the focus of today's presentation. Acculturated stress has been defined as an individual's response to stressors associated with the process of cultural adaptation and intercultural contact. Again, we're using various ideas of acculturation, including A, being considered of a minority status, B, needing to learn a new language, and C, negotiating cultural values between one's native and host countries. Acculturated stress refers to psychological stress reactions that occur in response to and alongside acculturation. Acculturated stress is separate but related to acculturation in that situational demands associated with cultural change tax individuals' existing behavioral and cognitive repertoires. So, acculturated stress is seen as one of the most salient ethnic minority stressors for Latinx individuals. It's the crux for the acculturated process in that it leads to severe distress at one continuum and low distress at another. The effects of acculturated stress on mental health have been documented and have varying positions. Positive association between acculturated stress and depression has been shown throughout many researchers. Acculturated stress and family cultural conflicts occur as well, and that's well documented within the literature. Family cultural conflict and depressive symptoms exist among the literature, among diverse Latinx samples, including youth. A quick side note, I struggle with the idea of Latinx or Latino population, and I try to look at some of the current literature as to what is everyone most comfortable with or whatnot. So, I may kind of go back and forth with the term. Latinx is widely accepted within a certain population, although some may not accept it. So, I tend to kind of utilize both. So, I just wanted to apologize for that in the beginning. Latinx Hispanic people are highly concentrated in a few states in the United States. The reason why it's important is because these are the states that are well populated with Latinos, so the impact is great. So, I want to kind of give a good understanding and background demographically of the Latino population, so I'll go a little bit into the numbers part. Obviously, there's a high concentration of Latinos within California, Colorado, Florida, Georgia, Illinois, New Jersey, New Mexico, New York, and Texas. It is estimated that by 2060, the number of Latinx Hispanic people in the United States is projected to grow to 119 million or 28.6 percent of the population. Its impact on mental health or its effects on mental health are U.S.-born Latinos, Hispanics, Latinx report higher rates for most psychiatric disorders than Hispanic immigrants. So, what we're looking at here is first-generation Latinos are reporting or discussing psychiatric disorders higher than their parents, and we'll talk a little bit about that. I'll touch a little bit about that more as I go. Studies have shown that older Hispanic adults and Hispanic youth are especially vulnerable to psychological stresses associated with immigration and acculturation, i.e., acculturated stress. Latino children and adolescents are at a significant risk for mental health problems and, in many cases, at greater risk than white children. One of the things that we find is a derivative of our factor in acculturated status is discrimination, and discrimination is an exasperator in that it can punctuate, highlight, and worsen symptoms of already underlying processes and diagnosis. Prevalence within the Latin community research shows that older adults and youth are more susceptible to mental distress relating to immigration and acculturation. So, those are the two vulnerable populations that are highly susceptible to acculturated stress during the immigration process in our older adult population as well as our youth. According to SAMHSA's National Survey on Drug Use and Health, overall mental health issues are on the rise for Latinos and Spanx between the ages of 12 and 49. I was looking for specifics regarding that in terms of the literature, but couldn't find a specific target area for that reason or whatnot, but that is definitely something that needs to be further explored. In regards to serious mental illness, rose within the population of Latinos from 4% to 6.4%. People ages 18 and 25. Now, 2.2% to 3.9% in the 26 to 49 age range between the years of 2000 and 2018. Now, I stopped at 2018 and didn't really look at, I did look, but I didn't add the 2019 and up just because we had this weird phenomenon called a pandemic occur in our country here, throughout the world I should say, and that kind of changed numbers a little bit. So, I haven't really been able to tease out, I haven't seen much reason to tease out those differences in those numbers in relation to the pandemic. So, I kind of stopped at 2018 just for the sakes of that. I really didn't want to present data that I wasn't too familiar with or didn't really know how it's teased out in context of the pandemic. With regards to major depressive episode, there was an increase from 12.6% to 51.1% in the Latinx Hispanic community within the ages of 12 to 17. It ranged from 8 to 12% in young adults from 18 and 25 and 4.5% to 6% in the 26 to 49 age range between the times of 2015 and 2018. So, we have evidence and support to see that there has been a significant increase in serious mental illness and depression within the Latino population in varied age ranges. So, we see steadily this particular rise. So, what can be occurring or what's happening and why do we see this happening? Well, there is a lack of knowledge of the information in that health care providers lack of cultural understanding may contribute to underdiagnosis, misdiagnosis of mental illness. Because of that lack of cultural understanding or underdiagnosis of mental illness, we see untreated individuals that tend to have their symptoms get worsened over time because of lack of treatment or treatment resources. Acculturation varies within the community. It's not just about immigrants, but a process for Latinos in general. Acculturation does not just, just because an individual is immigrating to this country, doesn't mean that the acculturated process ends there, but still continues with first-generation Latinos, second-generation Latinos. By third-generation Latinos, we tend to see a lot of the acculturation process kind of subside by then. Obviously, there's still issues and stressors and struggles that individuals go through, but we tend to see a lower rate of acculturated issues from that particular time frame. Going back to Latino mental health, Latino youth have experienced higher rates of anxiety symptoms. And again, this is pre-pandemic information at this point. Almost 29% of Latino youth met criteria for clinical levels of anxiety, which is a pretty high level of anxiety for that particular population. Compared to European American children, Latino American youth report higher levels of anxiety symptoms, according to the U.S. Department of Health and Human Services. Across Latino populations, acculturated stress has been found to be associated with anxiety symptoms. So, I think what we're trying to do or show is that there's obviously a need, and there's definitely a connection between the acculturated process, acculturated stress, and Latino mental health. The United States demographic has been steadily changing. Latinos have been a fast-rising population in the United States. Approximately 60.6 million Latinos live in the United States. They compromise 18.5% of the total United States population, the majority of which identify as of and of Mexican descent. Notably, the proportion of the total U.S. Latinx population who are immigrants has declined from 40% to 33%, which means that the projected rise in the Latino population is of U.S.-born Latinos, not newly arriving immigrants. So, what we're seeing is that a lot of first-generation, first-born Latinos are what's increasing the population. And, in fact, what we see with first-born generations is where we see a lot of the discrepancies and a lot of the issues with acculturated stress and depression and anxiety is that the children of immigrant families is where we're really looking at a lot of the significant concerns. Excuse me. Latinx disproportionately encounter risk factors for adverse mental health outcomes, including unique psychosocial stressors, such as racial and ethnic discrimination, a loss of related to migration and family separation, public policies that contribute to hostile and stigmatizing social contexts, and the process of navigating between and within multiple cultural contexts. Now, obviously, this isn't a lecture on politics, and we won't go into any of the political changes or stress that we've had in the last 10 years, but that plays into a factor. When we see such factors such as the building of the wall, or we see family separations with kids in cages that we've seen, that adds to and increases the acculturated stress that one is already experiencing just through the normal process of acculturation and migration. We see that being able to travel once between two cultural groups is a difficult process in of itself, notwithstanding political strife and or discrimination. And one of the things that I always kind of talk about with traveling between cultures is, for those of you that are familiar with the old Selena movie in that, you know, I'm neither Mexican nor I'm American. I have to know who Pedro Infante is, yet I have to know who John Wayne is. It's that it's a very hard process to be able to understand two cultural groups, two cultural identities, and try to integrate them. Depression and depressive disorders have been found to be one adverse mental health outcome that is particularly influenced by cultural context among Latinx individuals. And this is some more of our recent data is that depression is a factor, and it is an outcome when it comes down to cultural context among Latinx. Cultural stress has been shown to be a determinant in that it can exasperate already underlying depressive symptoms and or exasperate symptoms that are already present. So it can turn into a depressive disorder into a severe depression within the added factors of stress, such as factors of discrimination, et cetera. Despite considerable representation, Latinx experience unique stressors, including immigration, family separation, discrimination, and the process of navigating multiple distinct cultural contexts, which we touched upon a little bit earlier. These experience in of itself substantially contribute to adverse mental health outcomes, of which depression is one of the most commonly encountered. So what we see is in the literature and the research is that not only does the immigration process, but family separation, but discrimination, and the idea of traveling between two cultural contexts will exasperate and contribute to depression within the Latinx community. Yet we really don't talk about or assess or measure those factors when it comes to working with depression. We tend to treat the idiom, the idea itself of depression, as opposed to adding acculturated stress as a subfactor with dealing with depression. Acculturated stress is associated with adverse mental health outcomes, not only in depression, but poor overall wellbeing and self-esteem, depression, PTSD, psychological distress, and substance abuse and use. So we're seeing that acculturated stress not only has a large impact in depression, it has an effect in other varied areas of Latino mental health, such as PTSD, substance use and abuse, overall wellbeing and self-esteem. While we know that discrimination is a factor in acculturated stress, it is associated with higher symptoms of depression. We see it in cigarette smoking and lower self-esteem and alcohol use. Excuse me. So acculturated stress and its side effect of discrimination or a subset, excuse me, of discrimination increases the likelihood of depression, exasperates depression, but we see it exasperating cigarette use or smoking. Nowadays, a lot of vaping, alcohol use and self-esteem. The older population in the United States as it's aging, the diversity of it has been aging as well. It's shown to have a greater risk for Alzheimer's disease and related dementias compared to non-Hispanic white adults. In regards to severe mental illness, adults with severe mental illness, such as schizophrenia, schizoaffective disorder, delusional disorder, bipolar disorder, severe major depression disorder and psychotic disorders have a 25 to 30 year reduced life expectancy and disproportionately greater rates of medical comorbidity compared to the general population. So what we're experiencing here is that when you have Latinos who have a strong orientation to families and whatnot, we're seeing that it's not only impacting their mental health, but it's impacting their family functioning with the older generation potentially having a lower life expectancy where it's disruptive to the family unit and disruptive to family resources. An estimated 30 to 65% of adults with serious mental illness live with family members. So if we know that those individuals with severe mental illness live within the family, but we're seeing a life expectancy decrease within that family, it adds to the stress or cultural stress process and that we see a disruption within that family unit, especially when a lot of Latino families experience strong matriarchal or patriarchal hierarchies. Some of the cultural stress and its effects. Racial and ethnic disparities in mental health care utilization are a growing concern in the US healthcare system. Despite the high prevalence and severity of mental disorders among racial and ethnic minorities, minorities are less likely to seek psychological help even when they do, they are more likely to terminate prematurely. So we have a lot of factors that go on into mental health care and concern with Latino populations. A lot of individuals, Latino, Latino set, don't seek out psychological help. And I always tell the story of, when I first became involved in psychology and the idea of becoming a provider, my parents had no idea or no clue what my role was or what my job was. Their ideas still concerned the thought or the attitude of, oh, you know, vas a trabajar con esos locos, you know, estas trabajando con gente loca. So in other words, I'm working with crazy people. And that was their view. That was their understanding of what it is to seek psychological help is that I must be crazy or someone must be crazy to seek help. And it's not a unique position or unique stance that my family held. It's a position that the culture itself still had. They don't talk about mental health. It was not something that was largely discussed. And if it was, you know, it was kind of pushed back into, you know, oh, it's okay. It's just, you know, it's just a little problem here. It'll go away kind of thing. So we weren't encouraged to actually seek out help. Other factors interplay in that, that I'll touch on a little bit more, involve the idea of the fear of seeking out help. I know a few years back with the political strength that was going on in the country, a lot of our Latino clients in some of our clinics were scared to come in, did not want to come in out of fear of being deported or fear of deportation. So they didn't seek help because of the fear, which the symptoms exacerbated. We had a lot of children in schools that ended up having problems and got into trouble because weren't following through on referrals or recommendations out of that fear of seeking out help because of that sense of being deported. So the political arena also exasperated those particular symptoms. In terms of terminating treatment prematurely, I think that's something that's kind of still, we don't have a finger or a pulse on why individuals terminate treatment prematurely. Overall in mental health and in chiropractors, we see that a lot of our clients terminate prematurely. So it's not something necessarily a phenomenon only within the Latino population. It occurs throughout all populations, but Latinos also seem to be doing it at a little bit higher rate than others. And we're not quite sure why. There's been a lot of research speculation in the idea of, because they can't identify with the providers. And one of the things about identifying with the providers is that we have a lot of providers that may speak Spanish and that are bilingual, but are not bicultural. And bicultural piece is a very important part in the therapeutic process, because it allows for the individual to actually see the subtle nuances of the culture that you may not see if you have no experience within that particular culture. So that makes it very important. Now, when you're dealing with a clinician or a therapist and you're working with them and you don't feel like you have that connection, that's gonna cause a first sense of disruption and a sense of not wanting to be in treatment anymore. The other factors are is that, oh, hey, my symptoms are gone. I feel better, I'm done. So aftercare or prolonged care aren't necessarily seen as something that's necessary. Hope has positive effect. We all know that hope is a very important factor within suicidality and a large factor within suicidality, but it's a productive factor among families who are low acculturated Mexican-Americans. We see that the sense and the idea of having hope does raise the protective factor within these particular populations. So it's something to be looked at and investigated when working clinically with individuals is the establishment of hope and the assessment of hope. Most people tend to use hope or look at hope as a big factor just for suicidality, but it is an overall overarching factor in just better wellbeing. Mental illness is viewed on a continuum by Mexican-Americans, which allows the family to maintain hope for their loved one's improvement. Research within Mexican-Americans has indicated that rather than viewing mental illness as a static diagnosis with poor prognosis, families often view it as using idioms of distress such as nervios. So we've all heard, and my mom is notorious for this, is, me esta dando ataque de nervios, which means, loosely translated is, I'm getting an attack of the nerves. And then she would say, oh, you know, I need some nerve pills. And I remember as a kid, I'm like, nerve pills? What are nerve pills? You know, I've never heard of it. Even when I went to school, I was still trying to understand, well, you know, I wanted to ask, but there was a tendency of asking, what exactly are nerve pills? But it's such little nuances and idioms like that, that not having that biculturalism, you're gonna think that, you know, there's other disorders or much serious level disorder because of that. So it's understanding those idioms that are important, understanding the effects of hope on those idioms are also very important. When it comes with understanding our children, the impact, children under the age of three are at a particular risk for living in low income environments for nearly half living within 200% below the poverty line. Excuse me, infants and toddlers from racial ethnic minority and immigrant backgrounds are overrepresented among young children living in poverty. So children are a definite need for looking at understanding when it comes to the Latino population is understanding the poverty line. That alone is a stressor that's attributed to a cultural distress that has to be a factor when we're dealing and working with children mental health. Despite this increased risk for developing negative mental health problems and behaviors, Latino youth and their families are less likely to receive necessary mental health services and are more likely to terminate prematurely, which we touched on a little bit earlier. I don't think it's a surprise to anybody is that insurance plays an important factor when it comes down to receiving services. If they don't have jobs or the jobs are not providing insurance or whatnot, it's very difficult for individuals or anybody to be able to afford good mental health care. So that's a big factor when working with populations like this is dealing with and resolving the underserved, underrepresented, underinsured individuals is how do we accommodate for those services? I know at least in Illinois, one of the things is that there are places where you can get services that have sliding scales or accept MCOs or whatnot. But one of the biggest complaints that I get from a lot of our families is that, yeah, the wait list is so long. I've been waiting four months already and I still haven't gotten treatment or I still haven't gotten an appointment set. And it's interesting because when we look at families, let's say if they had cancer or had some severe physical ailment, a wait list of four or six months just to receive initial treatment would be unheard of. It would be on the news and like, how can we wait so long? But yet a family that's dealing with schizophrenia or someone who has severe depression is suicidal. We can put on a wait list for God knows how long until they're able to get those services. So there's definitely a discrepancy between physical and mental health within our nation. So there is some discrepancies in the literature and I don't wanna touch too much on discrepancies because it can be a little bit confusing. And again, given the time constraints, it's kind of hard to go into fully all that. But when you look at highly acculturated individuals associated with higher depressive symptomologies is something that I wanna kind of touch with. So when you look at the immigrating individuals, it's not the arriving immigrant acculturates that we see higher levels of depression with. It's actually the first generation Latino. So their first born to actually have a report higher symptoms of depression. There's mixed research as to why we see those particular numbers or see that particular discrepancy. And a couple of things that I'll kind of address is that one of the ways that it's kind of explained or expressed is that when immigrating Latinos come to the host country and they compare themselves to where they are, their status, they're comparing themselves back home to the old country and what they had there, what they lacked there, what resources they didn't have. And then they compare themselves here and they feel much more accomplished. So it's definitely a sense of higher self-esteem is that, hey, I have more here than I did there. Unfortunately, for our first born generation, when they're comparing themselves or looking at their counterparts, they're comparing themselves to their white counterparts. And because their white counterparts may have much more financial resources or better things or whatnot, that can exasperate or support the anxious symptoms or depression. So that's one understanding of what could be happening. The other thing that we see in the research is that the first generation may be more comfortable with reporting their depression and much maybe more comfortable with talking about depression while immigrating Latinos may not still wanna discuss it or may not want to admit to feeling depressed or having symptoms of depression. So they're not looking for treatments or seeking out treatments while the first born who have acclimated or I cultured it a little bit more to the group are much more open to discussing their symptoms of depression. We see this also occurring in eating disorder symptoms, general internal, excuse me, English is a second language for me, internalizing symptoms. Some research also suggests the Latino acculturation maintaining aspects of traditional Latino culture may be a protective factor. So what we see is that individuals who still hold on to a lot of their traditional traditions, beliefs and values, that that actually helps with the acculturated process and or fighting mental illness is they're identifying with and holding on to or acculturation within their culture is seen as a good resource for them to help with certain mental illness. And this is kind of one of the things that years ago in my dissertation, I did some work on gang membership and acculturation in Illinois outlook of it. And how I kind of understand the research or whatnot is that what I come to find in my study and what occurred is that individuals who were less acculturated actually remained in gangs longer. And individuals who were much more highly acculturated got out of gangs sooner. So we see almost an opposite effect. And one of the things that we saw with individuals who joined gangs was that they were joining gangs that has such things as, for example, Latin Kings, Latin drivers, Latin eagles, and they were using ethnic monikers. So what the gang was providing for them was a sense of identity and strengthening identity. Imagine joining a gang where you're being told, you're a King, you were born a King, and this kind of high Latinoism, it raised their self-esteem, albeit it's a very misguided and misdirected function, but that sense kind of helped identify, helped them to gain their identity and a sense of welcoming for their identities, what we saw with the military and gang research. So one of the important things is assessment. And I talk a little bit more about assessment because I think it's probably one of the most important things. When we do an initial assessment of an individual, we really don't know where they fall. A number of researchers have tried to develop acculturation scales and indices for Hispanics in the recent past. And I kind of took this from Mara and Gamba. There's a whole list of people that have done acculturation scales. So there is not a need for more acculturation scales within that community. There is a long list. And some of the most popular ones that we see is the acculturation range scale for Mexican-Americans, which I have the most familiarity with, excuse me, the children's acculturation scale, the bi-dimensional acculturation range scale for Hispanics, cultural lifestyle inventory, bicultural scale for Puerto Ricans, multidimensional measure of cultural identity, and the Stevenson multi-group acculturation scale. These are some of the most popular or most used scales that I've seen. And I probably have seen more of the Arzima more than anything being used within the measures. Now, it's important to mention and say that acculturation range scales are not only for Latinos. It isn't just for Mexicans, Puerto Ricans, is that you can actually find acculturation scales for almost every cultural group that exists. If you do the research and look, you can find scales that are used for assessment. The thing, the concern or level of concern for that is that we don't see them being used very much when it comes to mental illness. You don't ever see within any kind of initial assessment a level of acculturation. And one of the debates or one of the things that you have to keep in mind when looking at these scales is that a lot of the scales measure a component or a significant component of measurement is language use or facility of language, of English language primarily. And that is a big factor within measuring acculturation is that the level of ability to speak English. So there is a debate and argument on, well, is language use really that much of a factor when it comes to acculturation or not? And can it truly be used as a part of assessment? Some people only use language use and say, oh, they don't speak English. All right, and it's kind of a big factor when it comes to the treatment. So you're kind of seeing this kind of back and forth idea of language use as part of an assessment and part of its factor within assessment of mental illness. The way that I tend to look at it, my experience is, is that there should be a basic understanding of what level of acculturation that individual is, notwithstanding only language. And an example I give is I speak a lot about my father. My father is, truly speaks English, can read it, write it, but still holds on to much more of the tradition values and beliefs of a Mexican than he does more American values and traditional beliefs. So his acculturation level would actually be lower, yet he scores high on the scale because of his familiarity with English. So that's where we see those discrepancies is that we really have to get down into the contextual questions of those scales and really look at where does the individual fall? Again, it's important to understand those contextual variables because understanding that basic sense of where they are acculturated will help open the idea to see how much or how significant acculturated stress can impact the diagnosis. So we're working in tandem with looking at if the individual already has depression, is the acculturated process a significant factor in that depression? Is it exasperating depression? Could it be the root cause of depression? Otherwise we're spinning our wheels dealing with depression without really dealing with or working with the actual thing that's causing that depression. So that's why that initial is extremely important. Barriers to assessing mental health care. Obviously lack of insurance or inadequate insurance is a huge thing that we talked about. Lack of knowledge or awareness about mental health problems and services available, which is huge. The Latino community, there is a large portion that are unaware or not informed about mental health problems and reaching out to those communities is a significant factor, which is why acculturation, understanding acculturation is important is how we reach out. And one of the factors is that when you have individuals that don't look like them, us, is that there's that fear. So it's being able to reach these communities with individuals within that community that'll help educate and raise awareness and knowledge about particular mental health problems. There's a cultural stigma, so to say, with mental illness. That cultural stigma, that view, again, is also rooted in cultural stressors is that fear, that sense of like, well, I'm not crazy, I don't have this or whatnot. So education is extremely important. Language. We run several offices here and one of the hardest things is finding Latino providers, Spanish speaking providers. A lot of the first generation youth that we have can't speak English, but unfortunately the parents don't. And the difficulty then lies in, well, how do we inform the parents? How do we talk or communicate to the parents and let them know where the children is, what's going on with their children? That's where we find the biggest discrepancies. Lack of culturally tailored services and culturally competent mental health professionals. That's the idea when we look at bilingual, bicultural providers, is that while bilingual providers in of itself is definitely greatly appreciated and used because we have services being rendered, but there's that sense of not understanding the cultural context or not understanding the acculturated process or not utilizing the acculturated process as a factor for assessing mental illness and that it has its roots in depression, anxiety, et cetera. Assured bilingual or linguistically trained mental health professionals. Yeah, I mean, I don't think that's any news to anybody in that we don't have enough bilingual speaking providers for the population. Difficulties recognizing signs of mental illness. That's where we see the idiosyncrasies and the subtle nuances with mental illness within Latino and with that next population is that we can see somatization of a lot of mental health problems or we see a lot of minimization of problems and severe mental illness. And it's minimized because we don't recognize its cultural variables or its cultural context in that we don't really train to or speak to a lot of the cultural part or we see it in school systems where they teach a little bit about the cultural context, but then there's never an integration and assessment of how we assess for that cultural context or cultural variables. Problems identifying psychiatric symptoms with a cheek complaint is a somatic symptom and I think I touched on that one. So when do we assess or how do we assess? Well, generally within any incoming client, we have an initial intake, an initial exam, an ITP, which is an individual treatment plan. One of the important things is integrating some level of cultural assessment within the initial exam or the intake process outside of language of choice. It's understanding the fluency is that a given example is that just because the question is, which language do you feel comfortable in speaking with or what language is your preferred language and we check box, well, English, doesn't necessarily mean that we truly understand it or fully are functional within that particular language. An example I give is my mom, who I love very much, there's this tendency when I'm around English speakers, she'll speak English. Now she can converse and hold her own when speaking English, but I know, obviously it's my mother, I know when speaking to her, English isn't her first language of choice when it comes to dealing with any kind of emotionally latent material or describing things that are emotionally strong to her. And that would be Spanish, but she tends to speak English when she's around English speakers and Spanish when she's around Spanish speakers. Whenever I've been to positions, whether or not, she'll check box, yeah, she speaks English and will communicate in English and doesn't utilize Spanish. That's what we tend to see here at the offices as well, is there's this sense of like, yeah, I speak English, I can do it, but we really don't truly assess the level of competency with English and not just competency in terms of semantics and dialogue, but competency within how well you can emotionally express yourself, how well you can describe what you're dealing with emotionally within that language is something that we really truly don't see assessed or it goes on for several sessions before we go, I don't think that they can do this. If we were able to catch that earlier, integrate some level of a cultural assessment within the intake, we would be able to catch it earlier and deal with that process, as well as looking at what kind of stressors or cultural stressors are already existing within the particular family. If we understand those particular stressors, that would help really look at, all right, these are factors that can be contributing to anxiety, can be contributing to depression. We have to look at those factors in tandem with looking at depressive symptoms to see like, all right, how does it affect our approach or our treatment approach? We tend to kind of look at it in a silo as, oh, we're dealing with depression, let's deal with the depressive symptomology and look at it as diagnostically only. It's a depressive symptomology, not look at it as what's an acculturated stressor that's occurring. We're dealing with the acculturated stressor first, understanding that, and then seeing if the depressive symptomology subdues. We tend to kind of go backwards where it is, let's deal with the depression. So that's the kind of biggest things that we see. So the first step in understanding assessment is utilizing some level of assessment. Now, obviously, I'm not here to say, pick this one, use this. It's getting familiar with the acculturated scales and seeing which ones make sense to the provider and seem to be successful when working with it and integrating that within your initial intake, understanding where your client lies within the acculturated process. Having some background information that firstborn generations tend to have higher peaks in depression, understanding why that comes from can help and make for better treatment planning when keeping it in mind with acculturation. I think I'm here for time. And I just apply my bit that I refer to everybody. Thank you so much, Dr. Ramos. This was such a fascinating presentation. So before I shift into some Q&A, I wanna take a quick moment and let everyone know that SMI Advisor is accessible from your mobile device. Use the SMI Advisor app to access resources, education, upcoming events, complete mental health rating scales, and even submit your questions directly to our team of SMI experts. Download the app at smiadvisor.org forward slash. Okay, so I'm gonna get into some Q&A. So the first question for you, Dr. Ramos, is this. How do you decrease the stigma that some Latinos experience around accessing behavioral health services, specifically Baby Boomers and Generation X? So a lot of it is, so there's this big thing with, we've become a very globalized society in that everything, there's so much information at our fingertips with access to the internet, our cell phones, all this information is everywhere. And that even our Baby Boomer Generation is not immune to that globalization, is that they have access to it. So it's just being open about that communication seems to be something that sparks and triggers that initial conversation of like, huh, my dad, 84 years old, still can't work a VCR, but because he has access to all this information on TV now and hearing it, will actually ask and make questions about mental health, like, huh, do you think, I'll never forget years ago asking, do you think depression is something that's real? And something like that, to me was so, so impactful because it tells me that, when you have all this information flowing at you and coming at you, unless you're actively ignoring it, it is going in, it's just a matter of how internalized is it and what are the resources for you to be able to dialogue? Now, that's where I think the catch is, is that dialoguing of information. So one of the things that I like to do is go out into the communities, speak at churches, speak at libraries, speak at places where there's a strong Latino presence to be able to talk about those things that maybe at home, you can't talk about it with other family members or it's very one-sided within the home and having that ability to go, hey, well, have you thought about this? Have you looked at this? So it's really about education, but education in a safe spot, in a place where they're not having to go to a clinic and hear about it only, because that can be very scary for individuals. We have this idea in clinical work that meet the client where they're at. It really holds true is meet the client where they're at in their communities. Mm-hmm. Yeah, you bring me to the front, Sean, because my following question was gonna be around the topic of treatment planning. So the question was, do you factor in community involvement in your treatment plan? Just like you mentioned, the church, the extended family, the significant other. So that's a great question. So I don't factor in anything until I first understand where they're at and their level of acculturation. So depending on if they're first born, first generation, Mexican-American, if they're first immigrant to this country, that factor, those things will lead or factor in into how much they want community involvement. It'll factor in into how much they're involved in other resources, outside resources, or resources at schools, or where they're at. I tend to find that my Latinos who first immigrate, they're not gonna go into too many public settings that are outside of their community. So the first thing I do in any kind of treatment plan is let me see where they fall, like where are they at acculturation so I can kind of understand where their symptoms of distress are. Is it truly only just a biological component of depression or is it actively being exasperated by some of the stresses they're experiencing within the community, within life in and of itself? So it's really, the answer in short is really, it depends on where they fall within those scales. Thank you, thank you for that response. And shifting slightly over to rapport building with someone from the Latino community, how important is self-disclosure from the professional or from the person providing the intervention? How important is disclosure when working with the Latinx or Latino individuals? Correct, as the clinician self-disclosing a little bit about themselves to build that rapport. Gotcha, so that's a great question. So, I mean, I think it's, I always say, you have to be first comfortable with where you are as a clinician and be comfortable with what's okay for you in terms of your boundaries for disclosure or whatnot. So that's first and foremost. Two is that if you're gonna work with a Latino population, Latino culture, I can tell you that we are a very kind of open community. You know, there is a part of the culture where they're very touchy, like they'll put your hand on your shoulders or whatnot, and you can't see it as being necessarily inappropriate because it can be seen as offensive. There's a lot of gift giving. I mean, you don't know how many times I've had food brought into the office. And I remember going to school and being told, like, you can't accept any gifts and you can't, don't do this and that, you know, those are boundaries. And it's like, yeah, I agree. But if I turn down this, you know, older woman's, you know, tamales, she would see it as disrespect, like, oh my God, you didn't have it, you didn't try it. Now, what I've done over the times is that, you know, if she gives me a tamale, I don't just eat them all myself as much as I would love to. I kind of put them in the office and share it as a community in the office for everybody to have. So we often kind of have it. And then, you know, that way I can answer truthfully when asked, like, did you like it? I can say yes. I think the idea of boundaries or how much to share is rooted in how comfortable you are. Partly what, you know, I am obviously Latino, so I don't mind sharing my story with the internet. A lot of my story is all over the internet, you know, things that I do. You really can't hide a lot of outside things that you do much, you know, unless you're completely private. So I think they already have access to things. So for me to lie, if I'm asked certain questions, I think would rupture the therapeutic alliance already that we're trying to establish. So I tend to share certain things. I'm not gonna share, obviously, things that are extremely personal about my life. I don't think that's necessary, but it's important to share things that, you know, some of my interests, some of the things I'm involved in or whatnot. To do that, I think is comfortably okay for me and definitely shows within working with Latino populations. Yes, yes, it's being sensitive to the culture but also welcoming. So thank you for that. So I have another question. So clinically, how do I help a Latino who feels guilty about acculturating? I'm sorry, say that one more time. So there's a question asking about clinically, how do I help a Latino who feels guilty about acculturating, about kind of letting go of their culture and assimilating and so forth and so on? Oh, wow, that's a great question. So I have different answers for that, but I'm gonna try to kind of summarize it as best I can. I think there's always, I believe that there's always at some level, a sense of guilt. And what I look at is transitioning our culture and into the culture. As a first born Latino myself, I find it guilty that I can speak much more academically better in English than I can in Spanish. Unfortunately, I was, you know, my primary language was Spanish when I was first growing up and I learned English. Unfortunately, I learned English better communically clinically than in Spanish. And there is that sense of guilt, like, oh my God, I'm losing my culture, I'm losing my language and there's this fear and whatnot. And I see that sometimes with some of my younger clients is that they're like, oh, my parents didn't teach me Spanish, I don't know Spanish. Or they have certain things like that. There is that sense of guilt. I think that's an unfortunate part of a culture of distress is that fear, that loss of identity. And with that, it's integrating that into part of the treatment is, well, if you don't want to lose your language, what can you do? What can we do to help you still retain some of that language? What are the things we can do to help retain that loss or look at it? So one, it's identifying what's the guilt. And it's something that we can, is it something that we can actively change or work on? Or is it something that we cannot, that unfortunately is lost through our culture right through time that we just don't have it. What I find is that first generation, it's a little bit easier to work with because they're still that close to the family that they can still retain a lot of that identity. It's the second generation and third generation where it becomes a little bit tougher to kind of find things because now you're going back in years where it's a little bit harder to do that. Thank you, thank you. Our question chat box is flooded. So I have another question for you around peer support services. Do you find it personally, the need to integrate peer support expert or peer support services in the health care clinic as a form of integration? I'm paraphrasing. You cut out real quickly. So if I understand you, is peer support, essentially are you looking at is peer support useful? So pretty much what is your opinion on integrating peer support services in a clinic in a form of integration? Oh, I think it's extremely important. Peer support essentially is group therapy. There is no strong racial support. There's a difference between individual and group. I love having peer support groups with a population. Well, it's one of the things we offer is that we offer families a group session in which they can talk about depression, understand depression. And one of the things I find is that generally when you see someone else dealing with the same problem you have and has overcome it or learned something about it and shares it, you see this sense of like, really? And they tend to kind of run with it. So I find it extremely useful. Thank you. And the million dollar question that I don't have an answer to is, how do we attract more bilingual job applicants? That's like asking me, how do we cure depression? I wish I had an answer for how we attract because I think at the root is looking at, well, how did we get involved? And Hosanna, obviously you're a Spanish speaker as well. How did we get involved? And why did we get involved? And I think maybe a little disclosure here. I think if maybe all of the providers that are bilingual, bicultural, if we got to talk in our space and felt safe to be vulnerable and look at what got us into the field, why did we do this? And what was that one pivotal moment that made us change and go, I wanna do this for a living. If we started looking at that more openly, honestly, that was, I think, start to open the door is those are the things that help shape us in this direction. Maybe we look at that, we will maybe find a better answer, more answers as to how we can kind of open the doors or attract others to be in this field is that something sparked in us, something motivated us and caught us to do it. What is those factors? Let's look at those factors and reach out to populations, our populations that we can utilize those factors to reach out to. I think that would be a good start personally. Thank you, thank you. This is really helpful for the audience and also for myself. So I'm gonna move on to the next slide because we're out of time at this point. So if there's any questions that we've covered today or we'd like to discuss with your colleagues in the mental health field, I wanna encourage anyone to post a question or comment on the SMI advisor's webinar roundtable topic discussion board. This is an easy way to network and share ideas with other clinicians who participate in this webinar. If you have questions about this webinar or any other topic related to evidence-based care for SMI, you can get an answer within one business day from one of our national SMI advisor experts. This service is available to all mental health clinicians, peer support specialists, administrators, or anyone else in the mental health field who works with individuals with SMI. It is completely free and confidential. SMI advisor is just one of many SAMHSA initiatives that are designated to help clinicians implement evidence-based care. We encourage you to explore the resources available in the mental health addiction and prevention TTC. As well as the National Center of Excellence for Eating Disorders and Suicide Prevention Resource Center. These initiatives cover a broad range of topics from school-based mental health throughout the opioid epidemic. To claim credit for participating in today's webinar, you will have need to have met the required attendance thresholds for your profession. Verification of attendance may take up to five minutes, then you'll have to select next to advance and complete the program evaluation before claiming your credits. Lastly, please join us on August 18th. Dr. Ashley Austin and Dr. Lisa Rosano and Dr. Asher present An Introduction to Affirmative Practices for Transgender and Nonbinary Clients with Serious Mental Illness. Again, this free webinar will be held on Thursday, August 18th from 3 to 4 p.m. Eastern Standard Time. Thank you for joining us today and until next time, take care.
Video Summary
The webinar discussed the topic of acculturative stress and severe mental illness within the Latino community. It highlighted the need for culturally sensitive care and the impact of acculturative stress on mental health. The speaker emphasized the importance of understanding the acculturation process and its relationship to mental health outcomes. Various acculturation models were discussed, including the bidirectional model and the psychosocial model. The presenter explained that acculturative stress is associated with adverse mental health outcomes such as depression, anxiety, and substance abuse. The webinar also addressed the unique challenges and barriers faced by the Latino community in accessing mental health services, including lack of insurance, cultural stigma, and language barriers. The importance of incorporating cultural assessment and peer support services in treatment plans was highlighted. The presenter mentioned several acculturation scales that can be used to assess acculturation level in Latino individuals. Overall, the webinar aimed to provide clinicians with the knowledge and tools to effectively assess and treat Latino individuals with severe mental illness. Full credit goes to Dr. Edgar Ramos, the host of the webinar.
Keywords
acculturative stress
severe mental illness
Latino community
culturally sensitive care
acculturation process
mental health outcomes
depression
anxiety
substance abuse
cultural assessment
Funding for SMI Adviser was made possible by Grant No. SM080818 from SAMHSA of the U.S. Department of Health and Human Services (HHS). The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement by, SAMHSA/HHS or the U.S. Government.
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