Welcome, everyone. My name is Jose Villarreal, 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. The topic is The Impact of Immigration on SMI in Undocumented Latino Population. Next slide, please. 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 cares for those living with serious mental illness. Working with experts from across the SMI clinical community, our efforts have been designated to help you get the answers you need for the care of your patients. Today's webinar has been designated for one AMA PRA Category 1 credit for Physicians, one Continuing Education credit for Psychologists, one Nursing Continual Professional Development Contact Hour, and one Continuing Education credit for Social Workers. The link for participating in today's webinar will be available until September 5th of 2023. Slides from today's presentation are available to download in the webinar chat. All you have to do is select the link just to view the resource. Captioning for today's presentation is also available. Click Show Captions at the bottom of your screen to enable. Click the arrow, then select View Full Transcript to open the caption in a slide window. And please feel free to submit your questions throughout the presentation by typing them in the question area, also found in the lower portion of your control panel. I will personally be managing the chat, so feel free to submit suggestions, anything else that you have in mind, and I'll make sure to highlight it during the Q&A portion. I'll reserve 10 to 15 minutes towards the end of the presentation to answer those questions. And now I'd like to introduce to you all today's faculty for the webinar, Edgar Ramos and Sylvia Diaz. Edgar Ramos, Side D, is a licensed clinical psychologist with over 20 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 the Chicagoland area. Dr. Ramos is also an expert in the area of adolescent gangs. Sylvia Diaz is a licensed clinical social worker and bilingual provider at Erie Family Health Centers in Chicago. She focuses on the behavioral health integration within a medical setting. She has experience working with high-risk children, adolescents, and adults in various clinical settings. Sylvia has extensive experience providing clinical care to the underserved populations, which predominantly includes the Latino population and immigrant population. Among her accomplishments, she has implemented the straining families curriculum when working with parents and has worked on the research of Talleres de Jose to conceptualize these accomplishments. Thank you both for leading today's webinar. We're excited to have you present, and the floor is yours. Thank you, Jose. First, we want to start off by saying that neither one of us have any relationship or conflict of interest related to the subject matter of this presentation. And these are our learning objectives for today. You guys should have seen these prior. They are available in the slides as well. To start off, we want to talk about why is it important to discuss undocumented Latinx immigrants. Immigration adds complexity to someone's mental health due to the many factors that can vary case by case. When we're engaging with our undocumented population, we must approach each case with curiosity and from a trauma-informed lens in order to understand how the patient's individualized migratory experience and legal status can be impacting their mental health. We also want to make sure we're understanding and differentiating between the impact of someone being documented versus undocumented. In addition, what it means to have family members with different statuses and how that can impact individuals. We also want to understand the differences between acculturated and assimilated. And by doing all of this, this will help us to provide a safe space for this community and for them to engage and trust in our care. Some statistics for you. The U.S. is comprised of about 18.9% of the Latinx population, according to the Census Bureau. That does mean that they account for the largest ethnic minority group. It is also estimated that there are about 11.4 million undocumented immigrants currently living in the U.S. Fifty percent are estimated to be of Mexican descent, which is understandable given the close proximity of the country and then some of the immigration history that we'll talk about in a bit. Researchers also estimate that there's about 16 million individuals living in mixed-status families. In the upcoming slides, we'll talk about what mixed-status families are. Okay, obviously, this is not a policy presentation. But if we truly want to understand how documentation status impacts this population, we have to know a little bit about the history. We're not going to go into depth on this. We're just going to touch on some key points, okay? So we want to start off with the Mexican-American War. This is when the U.S. did acquire parts of Mexico, which included some of the West Coast states like California, Nevada, Utah. So there was already a Latinx population living in the U.S. The Immigration Acts of 1921 and 1924 came after, which is when the U.S. began limiting the number of immigrants coming from other countries, except for Mexico. Why? Because the U.S. needed Mexican laborers to fill in some of these seasonal employment gaps. In 1924 is when we recognize it as when criminalization began for border crossing. This is when the Border Patrol was established. We have the Repatriation Program, 1929-1939. This is when deportations began due to the Great Depression. Then there's the Bracero Program. You might be more familiar with this one. This one comes up in the literature a lot. And this is because it is looked at as the beginning of the objectification of Mexican laborers, okay? It promoted contracting Mexican workers for higher pay. So about 4.8 million workers were contracted under this program. As you can imagine, with the propaganda, it also increased unauthorized crossing. And so the literature looks at this as sending the message of, come when you're needed, leave when you're not. This is important to remember. Then we have Operation Wetback. I do want to note Wetback is a derogatory term, so please be careful when using this word. This was the second mass deportation, and it did include U.S. citizens. Then the Hart-Celler Act came in 1965. This was at the end of the Bracero Program, which, remember, the Bracero Program was promoting Mexican laborers to come. The Hart-Celler Act almost canceled all of that. They decreased the number of visas available, okay? And so this is looked at as the beginning of anti-immigrant view on Latinos politically, right? This is when we see a lot of presidencies campaigning. This is when we see an anti-immigrant view. Then we have the Immigration Reform and Control Act, 1986. Some of you may know it as the amnesty. This is when established undocumented immigrants in the U.S. were allowed to obtain legal permanent residency. Obviously, they had to prove that they've been working here for a certain amount of time, that they were living, and that they had a good background. Then we have NAFTA and CAFTA. NAFTA is the North American Free Trade Agreement. So NAFTA was between Canada, Mexico, and the U.S., and it was intended to help improve each country's economy, to increase trade. However, research later showed that it actually increased poverty in Mexico, okay? And therefore, it pushed families out of their homes because they were no longer able to afford living there. Similar situation happened with CAFTA. The difference was that CAFTA then now included the Central American countries and the Dominican Republic. Finally, we have DACA. There's a lot of mixed feelings about DACA. We'll touch on it in a bit. This is Deferred Action for Children Arrivals. This granted certain privileges to these individuals, and this is not a pathway to legal permanent residency. When we talk about documentation status, we're speaking about one's immigration status as determined by the Department of Homeland Security, okay? There are a few key terms that are important for you to know, especially when you're working with this population. So we're going to go over some of them. U.S. citizens, this is obviously someone who was born in the U.S. It doesn't matter if their parents are documented or not. If somebody was born on U.S. territory, they're considered a U.S. citizen, or they can also become through naturalization. Naturalization requires individuals to meet specific criteria before applying, and this also includes an interview and an exam. Then we have legal permanent residence. These are foreign nationals with authorization to reside permanently in the U.S. This also requires them to meet specific criteria, such as living here for a certain amount of time, having a visa, things of that nature. Unauthorized immigrants and undocumented immigrants are speaking towards anyone who crossed the border unauthorized, someone who overstayed their visa, or somebody whose temporary protective status ended, okay? When we're talking about deferred action, DACA, or some people refer to them as DREAMers, we're talking about individuals who have been granted privileges, such as being able to obtain a driver's license, being able to have a social security to find legal employment, okay? And these are foreign-born individuals entering the U.S. without authorization prior to the age of 16. When we talk about mixed status families, we're referring to families that include at least one undocumented individual and others who are either lawful permanent residents or U.S. citizens, okay? So this could be two undocumented parents and U.S. citizen children, it could be one undocumented parent, two undocumented parents and one undocumented child, and the rest could be U.S. citizens, okay? And then if you hear the word 1.5 generation, we're talking about foreign-born children who have spent their formative years in the U.S., okay? So think of these as individuals that may qualify for deferred action, it doesn't mean they will be granted. These are individuals who most of the time have no recollection of their home country, sometimes they don't even speak Spanish, it just depends, but their life has been in the U.S. and this is all they know, okay? When we're thinking about SMI, with this population, we want to look at the migration factors that can impact symptoms, and so we want to look at the context of exit. What was the reason for migration? As I said earlier, everyone's situation can vary case by case, it could be voluntary, it could be involuntary, it could have been planned, it could have been unplanned. So what do I mean by that? Somebody could be living in Mexico and has family in New York and decided that they wanted to move with their family, that they have no purpose living in Mexico anymore because they're alone, right? So they may be saving up money, they contact their family, yes, they may cross unauthorized, but maybe their family's waiting for them at the border, drives them, they have a place to stay, they have a work set up for them, that would be something more planned, right? On the other hand, you can have people like my family that I met about a month ago, who shared with me that they were living in Ecuador six months ago, and what they call La Mafia came to their home, knocked on their door and basically told them, if you don't pay us this amount of money, we're going to come, we're going to kill your family and we're going to take your home, okay? Obviously this family was very scared, all four of them picked up and left, they have young children, ages nine and five. This was so unplanned that they arrived to Chicago in December, in the middle of winter, had no jackets, and so unfortunately mom did catch pneumonia because they didn't have money to purchase jackets and she needed to go out to run errands, okay? As you can see, that could be very traumatic for that family and that experience is very different than the first situation I shared. Having said that, approximately 54% of Latino immigrants do leave because they've experienced political violence and then others do leave because of economic hardship. Remember what I said about NAFTA, there have been instances in history where Mexico's economy and other Latin American countries have suffered greatly pushing people out of their homes. We also want to look at migration journey. Are people overstaying their visas or are they hiring a coyote, okay? That could be very, that can also look very different, right? A coyote is somebody that is paid usually thousands of dollars to help someone cross physically over the border. And so when people overstay their visa, they usually arrive here on a plane very comfortably. They're here for six months and they decide to cancel their trip back, okay? That's very different than someone who plans to run through the desert, go through the river, and so we want to consider what dangerous circumstances they went through that could possibly be traumatic for these individuals, right? Did they go through extreme heat exposure? Were they freight train riding? I encourage all of you to look up a documentary called Which Way Home? It's a very good documentary. It follows children from Central America and their journey on the freight train and it just highlights all the dangers that they experience. It's not uncommon for people to witness the death of companions and be in unsanitary spaces, right? Sometimes we hear stories about individuals being in semi-trucks, being all with too many people, being in trunks of cars, okay? In addition, we also want to consider their experiences in detention centers. There is research that shows that there have been complaints filed in the past that circumstances are not favorable there. I did have a patient a few years ago and the reason why she came was because she shared that it was very traumatic for her to be at the detention center because she did have to come while she was pregnant and unfortunately she did not receive the appropriate care and she did end up having a miscarriage. That's one of the many stories that you might hear when you're working with this population. We also want to look at documentation status and how that may impact symptoms of SMI, okay? So legal violence is the suffering that results from and is made possible through the implementation of the body of laws that delimit and shape individuals' lives on a routine basis, okay? So think an example of this is this constant fear of deportation, okay? These families are constantly trying to live in the shadows. They are very careful with the forms that they fill, with the information they provide. I've had stories of individuals who are in car crashes and the ambulance comes and they're so afraid of being deported that they refuse any care and just leave when it's not even their fault, the accident wasn't even their fault, okay? And also the fear of potential separation from family, right? So let's think about how that can exacerbate some of these symptoms of major depression or trauma. Also we want to look at DACA, as I said before, there are mixed feelings about it. DACA is not currently a pathway to legal permanent residency. There is a real fear with it because it's not something that's set in stone. As you may recall a few years ago, it was put on hold and a lot of individuals did lose their jobs because they were unable to renew or show proof of their social anymore. And so think about it, as I mentioned before, these individuals are youth who were undocumented, okay? And they're basically telling the government, please give me permission to work and obtain a license. And the government said, that's fine, you can for now. And so there is a fear, what is the government going to do with that information later on, right? And we also want to look at legal exclusion, which is physical mobility limitation. A lot of other than DACA recipients, undocumented individuals are unable to obtain a license. They're not able to travel, right? So you might come across individuals. It's happened to me many times where my patients will say, well, I don't know what's wrong. I don't know what's wrong. And it turns out they haven't seen their family in 20 years and maybe their parents just passed away a few years ago and they were unable to say bye. And so now they're experiencing complicated grief and whatnot. And so these are real things that we need to address when we're working with these individuals. We also want to look at multi-generational punishments, and that's the phenomenon as a distinct form of legal violence, wherein the sanctions that are intended for a specific population spill over to negatively affect individuals who are not targeted by the law. Okay, so think of mixed status families, right? We have U.S. citizen children who even though should be able to have the same benefits as any other U.S. citizen, unfortunately are now limited because of their parent status, right? It limits their opportunities. For example, a lot of individuals won't apply for FAFSA. Remember what I said, the less information they can give sources that they do not trust or government entities, the safer they feel. And so sometimes they won't apply for FAFSA in fear that they will be caught and deported, their parents will, or because they simply can't prove income, because remember they cannot obtain legal employment. There's a shared economic instability. If their parents are undocumented, they're unable to purchase a home then, okay? And so we want to really consider the impact that someone's family, someone who has a family member who's undocumented, how that may impact our patient. I can't tell you how many times I've come across teenagers who will tell me that their focus is as soon as they turn 18, they want to work because they know they can obtain better employment than their parents just because they have a social, okay? And then of course, the constant fear of separation of family members, fear of deportation. Even though these are U.S. citizen children, they do still have a fear that ICE is going to raid their dad's job and they're not going to be able to see them when they come back. And this is a form of punishment for them as well. And so aside from all the documentation status factors and the migration factors that impact we also want to talk about acculturation. Yes. So going into acculturation is going to kind of tie up a little bit more on what all these processes are. So I'll start by first going over an example or a definition of what acculturation was defined as. And Gordon in 64 described it as a model as unidirectional and unidimensional where immigrants were situated along a continuum between maintaining their culture of origin and adopting the host country's culture. The implicit definition of acculturation was that individuals would relinquish their values or their culture of origin and assimilate those of the host culture. Assimilation is the cultural absorption of a minority group into the main cultural body. So the old definition of acculturation pretty much mirrored what assimilation is for those of us that understand assimilation. I'll kind of use the examples that when I was, back in the day, what I learned about assimilation and acculturations, assimilation was the old adage of the melting pot. You know, America is the melting pot, which is a very old term. We don't really use that anymore. It's kind of morphed and translated into the salad bowl. And I believe it's actually called something else now right now, but I'm a little behind on that, where in a salad bowl, we all retain each specific flavor or nuance of our culture. Next slide, please. With acculturation and assimilation is the idea of enculturation, which I think is going to be important to know, given the brevity of our lecture, I'm just going to hit some major parts that I think are going to highlight or punctuate what it is we're discussing here. So enculturate or the idea of enculturation typically is referred to one's orientation of the host culture. The term acculturation, on the other hand, can be used to describe one's orientation to the culture of origin. Now that in of itself is an interesting idea or concept. And I'll briefly just share that the idea of enculturation is when you look at certain neighborhoods and obviously we're from Chicago, one of the things in Chicago is that it's seen as one of the most segregated cities in the world. And the reason for that is that cities are developed or neighborhoods are developed in such a fashion to kind of keep certain groups of people in their place per se. And that's the idea of acculturation is that everything is within a block radius of what they need, never having to travel further or go beyond those particular means. Even a subway systems or the train stations, excuse me, kind of keep that process or that concept segregated. Next slide, please. A little bit about theory. John Barry, psychologist, is probably going to be the most pivotal person anyone hears or talks about for acculturation. It is the most commonly referenced authors or individual when we talk about acculturation models or acculturation ideas. He offered a bi-directional model with two attitudinal dimensions, the maintenance of the original cultural identity and desire to have contact and participate into the host culture. The combination of these two dimensions yields four particular acculturated patterns, namely integration, assimilation, separation and marginalization, which is the idea when we talk about marginalized individuals. Important to know when we talk about acculturation theory, looking at the unidirectional or bi-directional, excuse me, the best way to understand the idea of acculturation theory or bi-directionality is that it's a two-way street. When we used to think about assimilation is that you went into this host culture and you kind of relinquished everything about who you are, what you are, your old traditions, values, and adopted the new host cultures use. Acculturation on the other hand, and Barry's view is that you adapt some of the new stuff, but you also still retain some of the old stuff too. So that's the bi-directional and the host country also adapted to your stuff. And the easiest way we can kind of, if you want to think about it just an easy example is the idea of salsa. And I believe last I read salsa has passed and is now one of the, I think it was the first condiment or most widely used condiment in America, surpassing that of ketchup. Obviously salsa is a very Hispanic latent condiment. So that's an example of the acculturation or acculturation being bi-directional is that while we're adapting to the host culture, the host culture in of itself is also adapting to the culture. So further theory, the psychosocial model combines the four acculturation strategies that have integration, assimilation, separation and marginalization, which was described by Barry and the interactive nature of Burris model. It holds that acculturation process is influenced by the attitude and strategies of the immigrant population and those of the host society. A primary contribution was the introduction of psychosocial variables that may predict acculturated patterns such as expected outcome in group bias and group similarity. My next slide please. So acculturation is dynamic. It's a dynamic component of Latinx Latino individuals culture adaptation process and not limited solely to immigrants. So this is important to know as we go and delve deeper into the idea of mental illness, severe mental illness with this is that acculturation is not just for recently, new immigrants or immigrant individuals is that acculturation also lends itself to the process of those who are descendants of immigration or not. So, and I'll explain that further as we go throughout. Next slide, please. With acculturation. So we have an idea of what acculturation is and its foundation in theory, a subset of acculturation or something that runs hand in hand with acculturation is the idea of acculturated stress. It's an individual's response to stress stressors associated with the process of cultural adaptation and intercultural contact, including one, being considered a minority status two, needing to learn a new language, three, negotiating cultural values between one's natives and host countries. Acculturated stress refers to psychological stress reaction that occur in response to and alongside acculturation, which is more aligned with Barry's theory. Acculturated stress is separate, but related to acculturation in that situational demands associated with cultural change, tax individuals, existing behavioral and cognitive repertoires. Now, it's interesting when we think about acculturated stress, because we don't really talk about or see it in, and I'm gonna qualify this, in most circles, when we talk about mental illness or mental health, we really don't ever use any kind of measure or any kind of tool to assess for acculturated stress, nor do we actually put it on as a diagnostic criteria additive to what the primary diagnosis is. We don't really actually use acculturated stress, albeit it is a significant factor, especially for those who are dealing with or living with acculturated issues. So that's gonna be something that we're looking to kind of promote and push a little bit further. I saw an article not too long ago about acculturated stress and I think psychology today, which I was so happy, I was really cheesing when I saw that, because I think it's being pushed a little bit more and understanding that acculturated stress is a real problem. It's a real issue in adapting and being able to survive and struggle in their new host culture. Next slide. Acculturated stress is one of the most salient ethnic minority stressors for Latino Latinx individuals. So with that said, it is an important factor to understand, it's an important factor to assess for and to keep in the context of when working with Latinx individuals. Next slide. Some of its effects, and again, I'm just trying to limit a little bit more focus here. 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 ethnic minorities, minorities are less likely to seek psychological help. And even when they do, they are more likely to terminate treatment prematurely. Now, this is a huge thing. And I don't think for those of us that are practitioners, I don't think it's something new. I don't think it's something that we never heard before. It's a highly prevalent thing. Early termination is already large in treatment, but it's even more so when we're looking at individuals from other countries or ethnic diversity. So it's something that we wanna always keep at the forefront of our minds to understand the idea of why they're terminating prematurely. Next slide, please. Discrimination is a factor of acculturated stress. And I wanna be careful that it's not whole encompassing. It's not the whole thing, it's just a part. And what I mean by it's a factor of acculturated stress is that discrimination can look like many things. Discrimination can be discriminating just on a person's color, race, ethnicity, religion, all the above. Bullying in of itself can also be discriminatory. So that's a factor of acculturated stress. Bullying can be, I'll never forget, I think I just watched the movie, the Flaming Hots movie, whatever that movie was about the invention of the flaming hots and seeing this kid, the inventor of the flaming hot Cheeto, was eating a burrito, being burrito at school and the kids were bullying him. That is discriminatory, that's discrimination. And that affects and impacts acculturated stress as these kids were bullying because he was eating a burrito and to his, I won't ruin the whole movie for you, but he ended up hustling these burritos and selling these burritos and making money off of it, making a profit off of it. But initially he was getting bullied for it. So that was to me a good kind of highlight of discrimination that's not overtly just someone a name calling or being hit or whatnot. It's also just being bullied for the things you eat is a form of it. Next slide, please. Among Latino youth, discrimination, a negative context of reception and acculturated stress have been linked with elevated symptoms of depression. So we now know, and we do know that discrimination has an impact on depression as it may not necessarily be the cause of depression. I want to be very careful with that, is that it can be and may be exasperation of depressive symptomatology. It has been linked with cigarette smoking and alcohol use and lower self-esteem, all of which can lead into and open the door for much more severe mental illness. Studies have mostly shown a positive association between acculturated stress and depressed symptoms, simply meaning that while again, not necessarily the cause, the two things seem to occur hand in hand. We do see that individuals with higher forms of depression have also higher levels of acculturated stress. A side note that I want to point out is that when we think about immigration and early on Sylvia's presentation about the 1.5 generation, it's interesting because when you think about depression in the United States with let's say our Latino youth, it is actually higher reports of depression in first generation Latinos than individuals who first immigrated to second generation, excuse me, meaning simply that we don't see as high depression of individuals when they first immigrate to this country, but we see a higher form of depression for their children. And there's been a lot of studies done as to the how, why, or what's the notion. And there is arguably some consent or some consensus, excuse me, in the idea that when you see individuals who are children of immigrants, when they're comparing themselves or looking at their lives, they tend to be comparing themselves or looking at the lives of their American counterparts while immigrants still look back and go, well, back home, I didn't have a car, I didn't have this. So they have much more better cognitive resources than their children. So we do see a high prevalence of anxiety and depression for first generation Americans from Latino families. Immigrant studies support that cultural distress is associated with adverse mental health outcomes among Latinx individuals, including worse general wellbeing and self-esteem, depression and PTSD, psychological distresses and substance abuse and use. So we're seeing a lot of high outcomes that are worse overall in terms of mental illness and substance abuse in Latin individuals. Next slide, please. So some of the prevalence. So research shows that Latinx, Hispanic populations, older adults and youth are more susceptible to mental distress relating to immigration and acculturation. It just means that some of their lack of resources, of services impact and highly impact their ability to receive treatments. According to SAMHSA's National Survey on Drug Use and Health, overall mental health issues are on the rise for Latino populations between the ages of 12 and 49, which is a large portion of the population. Serious mental illness rose from 4% to 6.4% in Latino people ages 18 to 25, and from 2.2% to 3.9% in the 26 to 49 age range between 2008 and 2018. I haven't seen the most current stats yet, and I don't think they're fully out yet, and they may be, so please correct me if I'm wrong. Major depressive episodes increased from 12.6% to 15.1% in Latino and Hispanic youth from the ages of 12 to 17, 8% to 12% in young adults between the ages of 18 and 25, and 4.5% to 6% in the 26 to 49 age range between the years of 2015 and 2018. So we definitely see an overall increase in a negative of depressed individuals. Next slide, please. Overall Latino mental health, U.S.-born Hispanic Latinos report higher rates for most psychiatric disorders than Hispanic immigrants. So this is a little bit what I was talking about in that first-generation Americans tend to suffer more or report more, and I will add that, and as long as they can see me, I'm air quoting that, those that suffer from and or report more distress or psychiatric distress than their parents per se. And again, this can have many factors. Hispanic parents may be fearful of deportation. Belief systems about mental health can be factored, which is why they're not necessarily reporting. So we wanna always look at the numbers with a little bit of a grain of salt, and I always share the story of my parents is that when I went into the field of psychology, my parents had no clue what that was, no idea. So I had to try explaining a dissertation to them, and that was even much harder. But then when I actually started practicing, my mom, blessed with heart, she's like, oh, you know, my kid, my son, it's Dr. Alejandro Conocos, and what that means essentially that he's working with crazy people. And I'm like, ma, that's not what I do. That's not what I say, you know? And it's like, well, isn't that what you do? I'm like, no, that's not what it is. They have a very, she has a very old school idea. And then it's this, my dad's like, why can't people just do what they have to do? And very old school mentality of you should be able to get better on your own, and you don't believe in this mental health. And you see that prevalence within a large portion of the Latino community. In my practice alone, working with kids, their parents will always argue and kind of say like, I just don't understand why. They have everything, they have food, they have a roof over their head. I bought them, I buy them everything, and they're still depressed, and I don't understand. And it's like, well, you know, depression really doesn't work that way. And I go into my little spiel, but you still see that leakage coming in about these old school values of mental health, that it's not really, quote, a real problem. So that's something that you wanna keep in mind when you're looking at this. Studies have also shown that older Hispanic adults and Hispanic youth are especially vulnerable to psychological stresses associated with immigration and acculturation. So again, we're seeing that immigration and acculturation is a huge factor in mental health. It's a large factor when assessing for and understanding mental health is that stress. And we can look at it from a trauma-informed model is that, and we talked about fear, you know, stress and fear, is that when you have these biological systems activated, and I won't go full geek on you, everybody with the biological portions of it, but when you have these systems activated, they are causing not only biological distress, excuse me, psychological distress, but they're also causing biological distress. And that's something that we wanna look at and understand is that you have a dual complex individual of psychological and biological distress. Hispanic children and adolescents are at significant risk for mental health problems, and in many cases at greater risk than white children. Next slide, please. Continuing with Latino mental health, depression and depressive disorders have been found to be one of the adverse mental health outcomes that is particularly influenced by cultural context among Latinos. So we are looking at that it has, there's a specific component to the cultural context when looking at depression and depressive disorders with Latino youth, and that's something that we haven't fully explored. And while the research is growing, that's something that we wanna definitely explore and understand better. Despite considerable representation, Latinx experience unique stressors, including immigration, family separation, discrimination, and the process of navigating multiple distinct cultural contexts. These experiences substantially contribute to adverse mental health outcomes of which depression is one of the most commonly encountered. And for those of you that ever watched the movie, Selena, I always kind of tell this part when looking at this is that, and Barry would call this marginalization, but it's the old idea of neither one or the other, but yet I'm both. When I'm in Mexico, I'm more American. When I'm in America, I'm more Mexican. It's that I have to understand who Vicente Fernandez is in Mexico, but I also have to understand who Taylor Swift is when I'm here in America. So it's trying to manage and understand two cultures at the same time, adapt to those two cultures, appease our parents' opinions and views, but also still adapt what our peers. That is extremely taxing in our cognitive functioning and exasperates our depressive symptomology, which can lead to much more severe symptoms because it exasperates underlying depressions or other disorders. Next slide. One of the portions that we have is there is a lack of knowledge, and I see the slide says SMI lack of knowledge, and it's just, it makes me tickle because it doesn't mean that SMI has a lack of knowledge. So I applaud this for that. Healthcare providers' lack of cultural understanding may contribute to underdiagnosis and misdiagnosis of mental illness. And real briefly, all that is is that we don't necessarily understand the idiosyncrasies of particular disorders among many diverse populations, not just Latinos, we lack those idiosyncrasies. There's a difference between a bicultural, a bilingual therapist, and a bilingual bicultural therapist, is that the lack of being able to understand those idiosyncrasies can cause for an underdiagnosis or a misdiagnosis. Next slide, please. Adults with serious mental illness, such as schizophrenia, schizophrenia disorders, delusion disorders, bipolar, severe depression, psychotic, have a 25 to 30 year reduced life expectancy and disproportionately greater rates of medical comorbidities compared to the general population, which is what I was speaking to earlier, alluding to is that we have severe mental illness and physical ailments are compiled and individuals are having less lifespan because of these contributions. An estimated 30 to 65% of adults with serious mental illness live with family members. Next slide. Children under the age of three are at particular risk for living in low-income environments with nearly half living within 200% of the poverty line. Infants and toddlers from racial, ethnic minorities and immigrant backgrounds are overrepresented among young children living in poverty. Despite their increased risk of developing negative mental health problems and behaviors, Latino youth and their families are less likely to receive necessary mental health services and more likely to terminate treatment prematurely. And that's something that we're gonna constantly see throughout. I've been in prior practice for over 20 years and being able to grab these individuals and get them into treatment isn't as hard as retaining and maintaining them within treatment has become the most difficult thing. Latinxs disproportionately encounter risk factors for adverse mental health outcomes, including unique psychosocial stressors such as racial and ethnic discrimination, loss related to migration and family separation, public policies that contribute to hostile and stigmatizing social context, the process of navigating between and within multiple cultural contexts. Again, that's the old adage of being able to understand our culture of origin, but also maintain our culture, our host culture and navigate between those two when and when not to do something, when to do something and understanding those cultural idiosyncrasies is essential. Okay, and so when we want to engage with the undocumented Latinx population, we want to keep a few things in mind, okay? First and foremost, we want to use a multicultural orientation. We want to practice cultural humility, okay? And that means to be curious, to be humble, to be respectful, to be other oriented. We want to improve cultural comfort and that's our ability to engage in conversations about their cultural values. We also want to seek cultural opportunities, so finding moments to discuss culture within session. Ignoring harassment, acculturation, experiences, migration, those are considered missed opportunities. We also want to relearn history and this is why we decided to start this presentation with some history on policies in the U.S. Why? Because immigration laws are always changing and they're impacting this community. Think of the public charge rule a few years back. I can't tell you how many pregnant women would come to the clinic afraid of how they would receive prenatal care because they didn't want to apply for Medicaid now. They were afraid of how that would impact them in the future if they were able to obtain documentation. Also, zero tolerance, not too long ago that was heavily criticized for being unhumanitarian. As I said DACA, that's not set in stone, that sometimes has changes or is put on hold. We want to make sure we're up to date because then we'll know when it's impacting our patients. We also want to engage in self-reflexivity. We want to acknowledge our personal bias and privilege. Most of us here have some sort of privilege. I myself, my parents are Mexican, they were born in Mexico. The difference is I understand that when I was born they had a social security. They had a legal documentation which is very different from someone whose parents may have been undocumented, right? They could have been born the same exact day in the room next door and their experience, their opportunities would have been much different than mine and I have to acknowledge how that impacts the way I interact and I understand my patients. We also want to use the term undocumented instead of illegal when referring to this population. Research does show that when we use the term illegal it does create an internal bias and it's also contributing to the bias around other professionals that work with us. We also want to consider how our environment and settings may intimidate these undocumented patients, okay? For example, undocumented individuals are more likely to be open to mental health recommendations in primary care settings and this is where integrated behavioral health is important. We also know that the research shows that they feel safer in individual therapy versus group therapy, okay? So don't be surprised if you're recommending that they attend group and then that they're preferring to continue with individual. We also know that spaces within near or in connection to faith-based entities feel more welcoming and safe for undocumented patients. Obviously, we know we're not all going to work in a faith-based entity. However, this is still important to know because if you're going to provide a resource for your patient and you have to choose, you have five choices and maybe two of them are faith-based, I would prefer to refer them to the faith-based because then they're more likely to follow through with it, right? So I'll say things like, hey, Taier de Jose is right next to the church. You know, you'll see the sisters come in and out. They're very nice. I think they're going to be able to help you. It's more likely that my patient is going to go through and feel safe attending. We also want to use a trauma-informed and systemic approach when meeting with our patients, right? So we always want to consider social determinants of health factors, right? How are they preventing them from continuing therapy? $20 for you and I for a session may seem like not a big deal and important for our mental health, but remember, these undocumented individuals, their job is not stable. It's not promised, and so sometimes it is difficult for them to follow through if they don't have transportation and so these are some of the things that we can help. We can try to see if we can help buffer a bit for these patients. We also want to use evidence-based tools, such as the cultural formulation interview, which you should have as part of your handout, and then there are some others that we want to touch on. There are specific assessment tools used to assess for acculturation. I think that's something that's very important. That should be part of our initial intake, which I don't know why we don't, hasn't become a common practice, but it's something that we should at least consider, and side note, there is an acculturation rating scale for almost every cultural group out there, and my dissertation, I ended up using the ARSMA-2, so I have a particular affinity to the ARSMA-2, but I think it's something that's going to be very important. So here's a list of a few of the acculturation rating scales for individuals, so definitely something that should be at least considered or utilized. Don't presume or assume that just because an individual can speak both languages is that they may be highly acculturated or negatively acculturated. It's something that you want to definitely have some backing to assess. And this is just the handout that you guys have access to. If you want to look at it, you'll see some sample questions of how, when you're meeting with patients, that you can use, okay?, and then on the slides, you'll, you have our references. If you want to look through them, you're more than welcome to. Thank you for such an interesting presentation and for a timely presentation, given everything that's happening across the nation. Before I shift into some Q&A, I want to take a quick moment and let everyone know on the call that SMI Advisor is available from your mobile device. Use the SMI Advisor app to access resources, education, upcoming events, complete mental health rating scales, and even submit questions directly to our team of SMI experts. It's as easy as downloading the app. The app is smiadvisor.org or slash SMIAdvisor.org. Okay, next slide. So, the Q&A portion of this platform has been lit up. We have a lot of questions. We have about 10 to 12 minutes to field those questions. So, I'm going to start with some initial questions pertaining to engagement. Sylvia, you mentioned some strategies to make sure that people stay connected. Edgar, you mentioned some assessment tools that we can leverage to make sure that we're asking the right questions. Do you have any advice on how to encourage collaboration, sharing of the story, identification of the problem, identification of the solution when working with Latinos, given the fact of everything you mentioned? Sylvia, would you like me to go or would you like to answer? Go ahead. So, I mean, obviously, I mean, I'm trained as an old psychodynamic, psychoanalytic psychologist. So, obviously, the first thing I do is I want to understand who I'm sitting across from. So, I never presume or assume that just because they may look one way or speak one way that they are that particular way. So, it's one understanding, bare minimum, is just understanding who is across from you. And it's funny because you don't really know and understand how important that is, is just being able and willing to listen to who's sitting across from you. Once you have that, I would hope that, I assume that your clinical training would best direct you into going, all right, you know, I'm going to take these particular measures. And I think that's probably part two of not knowing just who's across from you, but part two is knowing what tools and resources we have that do have some backing, the evidence backing, to be able to utilize those tools to actually then incorporate them into clinical understanding. Not just assume that, oh, well, the BDI, you know, the Beck Depression works for everybody. Well, you know, it depends on how well they can read it and what those words mean for someone that, you know, may not be fully adaptive or acculturated with, you know, English language. You want to be able to use that, which is why, again, got to know who's sitting across from you. You got to know where they're at before you actually grab tools and just assume that, you know, your standard mental health or MMSE is going to work the same as with everybody. So, understanding who they are will help you understand what tools you can and cannot use. Do you want to add to that? If not, I keep asking other questions. I would just like to add, you know, again, a part of the handout was the cultural formulation interview. And as I said, there are sample questions there to prompt you to be able to discuss the patient's definition of the problem. So, definitely take a look at that after the presentation. Yeah, that's a really important aspect for providing care for the Latino population is taking your time, being aware of why they're here, being aware of the concerns or questions that they have in order to really identify the problem. And someone was asking about early termination and ways of engagement. And I feel like you both answered the question directly is by allowing the process within treatment to feel welcoming, to feel like it's collaborative, if they have to add other resources or other people within the clinical care because Latino family include their extended family. So, thank you for answering that. So, Dr. Ramos, specifically for you, you were talking about the assessment tools. And I have many conversations with you around using these assessment tools and being clinical, clinically astute in how to ask questions. We know that a lot of folks within our community use the ACEs tool, but we know that the ACEs doesn't take into consideration occulturative stress. Is there any question we can learn how to use or pivot during that specific assessment to identify the occulturative stress that you spoke about? So, I'm one for having something that I can back up if ever questioned. So, for me, it's quite simply is use that assessment, use the ARSMA-2 if you need be. Don't presume. After many years of practicing in school, it has come to, well, it's always come to my realization that we tend to try to standardize our tools and unfortunately, our psychological tools, our counseling tools, social work tools to assess for everybody. We generalize everybody and or we generalize a diagnosis and symptom for everybody. In other words, is that we tend to use measures that are very sensitive, but lack specificity. Is that we are very quick to just go, well, you know, they're depressed. They answered all these questions. They're definitely depressed. And we really don't understand the context behind that. And that's where it's like, you really have to probe and understand to know how to ask the questions, but also know how to use the tools that are effective and useful for that particular population. So, it's understanding all the materials that are in front of you. And the only way we can do that is obviously by one, looking at presentations, continuing our knowledge is reading and understanding the cultural groups that we're working. We just can't assume that just because they may have been in America for 50 years that, oh, they're American. They may be, obviously, documentation wise and we want to label them, but that doesn't necessarily reflect who they are clinically. So, you want to really get to know them, ask questions, use your tools, and then try to package all that into better understanding for the individual. And Dr. Ramos, one follow-up question. In regards to really challenging our unconscious bias, our colorblind paradigm, and learning more about culture and being culturally sensitive, what recommendations do you have for the audience? What are things that we can do to immerse ourselves in the different cultures of the folks that we provide in order to be a little more sensitive and careful? So, cultural sensitivity has a unique play in my mind and my heart is that you have to ask questions. And I'll tell a little story about you and I that you used to mimic my behaviors in therapy when I would say, can I challenge you? I would always ask permission when I was going to do something that may be seen by others as I'm challenging them or I'm coming at them hard. Well, I'd always say, can I challenge you? And then for some that was like, well, I don't know. I'll give them my little speech like, hey, if it knocks you down, I'll assure that I'll pick you up, blah, blah, blah. So, you have to be as sensitive as a person can be, but you can't presume that the person understands who you are. So, you have to be open to dialogue and be open to asking questions and not be ready to just be scared to ask those questions like, well, what's the difference between a Hispanic and a Mexican? Is that the same? Do you speak Mexican or do you speak Spanish? You have to be able to listen to that and go, well, if they're genuinely asking, oh, okay. So, you have to be one open to the questions. That's probably the biggest thing is sensitivity is being able to ask those questions and that you may get an answer that you don't want to hear. You may get someone that takes offense to it. You may get someone that's open and willing, but the only way you're going to learn is by being able to ask the questions. The sensitivity is in how you ask those questions. Don't presume you know how to ask that question, asking it in a manner that's respectful to the person sitting across from you, I think is probably one of the most important things. I learned so much from my clients and my patients by asking them questions like, what does that mean? I'm like, I've never heard of that. What does that mean? I generally don't know what that is. You'll find that most of them are quick and willing to go, oh, this is what it is. Like, oh, that's great. I learned something and that's the wonderful thing about what it is we do. Yeah. So interesting. You're taking me back to my days of supervision as an intern, Dr. Ramos. And I love the framing of that specific concept because I remember you encouraging me to be open to being challenged by the patient when I felt like I knew it all. As an intern or as a clinician, you were always telling me, you're not an expert in their lives, so you have to be a listening party, not necessarily a person listening to respond. So thank you for sharing that. So I have a question for you, Sylvia. We talked about the impact that the whole demographic has, this whole population. How do you provide sensitive care for adolescents who may be experiencing an adverse reaction around acculturation when they have parents that are heavily involved? Some people call them helicopter parents or over-concerned parents. Is there a strategy to deal with that specific aspect? When I worked with the youth, and I know it depends on where you work, right, on the resources that you have. But when I worked with this population in general, I think Latinos, family is very important to them. And as Dr. Ramos mentioned, treatment involves their family as well. And so usually what I would do is I would work with my teens, but I would also make space for the parents so that they felt heard and that they felt like I was taking into consideration the family dynamics as well. And obviously, we also want to include the family whenever in session as well. Thank you for sharing that. And I always tell the parents, you give me the opportunity to engage with them. I'm going to encourage them to participate with you. I can't 100% say that they are willing to work with you, but give me the opportunity to work. And on the other end, when I'm working with the youth, I let them know, I'm going to teach you strategies to help your parents give you a little more space in order for you guys can get along a little better. But we're going to deal from different aspects, never disclosing what you share in the clinic. The last question, Dr. Ramos and Sylvia, we all know that there's a big word, right? Systematic racism, systematic oppression. What can we tell our patients, the people we serve, the people we provide care around accessing care when they're afraid that you walk into the clinic and you may get reported to immigration, you walk into the clinic and something bad may happen out of your fear for trying to take care of your physical and mental health? Well, I mean, I can say is that as a clinician, I'm not mandated to report because you don't have a valid social security number. I don't necessarily care if you have a valid social security number. That's not, you know, one of the things I tend to offer is if you don't have insurance or whatnot, you know, obviously we offer services that are sliding scale. And I think Sylvia, you said $20 may seem like a lot. My sliding scale is very simple is that if you're working, how much do you make an hour? That's what I charge you. You know, whatever you make for one hour, I'll charge you for one hour and that's fine. So I, that's how I try to be in that term, sensitive to what it is they do. I do have to value what it is I do, but I have to value and appreciate what it is that they're making as well. So I think that that's important, but how do I make it ease their mind about, you know, not being reported or being that? Unfortunately, we live in an era right now where that fear is so prevalent that it's really hard to take away that fear. The only thing you can do is offer that peace of mind. But taking it away, I truly, I don't, I can't perform magic. I wish I could, because that would really make things a lot better in this country, but I don't know how to do that. I'll tell you that straightforwardly, I don't know how, I wish I did. My only recommendation would be thinking back to the public charge rule when it came out. I think a lot of fear around it was, okay, if I apply for Medicaid, then later on, if I have the opportunity to obtain social security, I'm going to get denied because I got Medicaid. And so I would say if you're working predominantly with this population, always have free legal advice, hotlines. There's a lot out there available because that's my way at least of trying to buffer that stressor where I will tell my patients here, I have, I can't promise you that I know exactly how to answer this question, but here, why don't you try calling this entity? As I said, I personally, I like to refer them to Catholic charities in Chicago, and that it's again, faith-based. So having those in your pocket as tools to be able to provide to patients is also helpful. Thank you for all this information. I, yeah, it's really important to be aware of the impact of offering hope and like the Rama would always say, you can't offer hope to somebody, the worst thing you can do is take it away from them. So it's having that foundational approach to how we provide care in a sensitive way. So I'm going to move on because we're out of time. Can you proceed to the next slide, please? So if there is any topic covered in this webinar that you would like to discuss with a colleague in the mental health field, post a question or comment in the SMI advisors webinar roundtable topic discussion board. This is an easy way to network and share ideas with other participants that were in this discussion today. Or 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 anybody else in the mental health field who works with individuals with SMI. This service is completely free and confidential. Next slide. SMI advisor offers evidence-based guidance specifically to the Latino population, such as the webinar assessment and clinical understanding of acculturated stress on severe mental illness within the Latino community. This webinar discusses meaningful measures of acculturation and the incorporation of measures within the clinical setting. You can access this webinar sheet by clicking on the link in the chat or by downloading the slides. To claim credit for participating in today's webinar, you need to have met the attendance thresholds for your profession. After the webinar ends, please click next to complete the program evaluation. The system then verifies your attendance for credit claim. This may take up to one hour based on your local, regional, or national web traffic, and the uses of Zoom platform. Next slide. Last but not least, please join us on July 20th as Dr. Darlene King presents Selecting Apps for Severe Mental Illness, How to Evaluate Apps and Incorporate Them into Clinical Practice. Again, this free webinar will be held on Thursday, July 20th at 3 p.m. Eastern Standard Time. Thank you all for joining us, for staying a little over, and I'll see you guys next time. Take care and have a great day. you

immigration

serious mental illness

undocumented Latino population

webinar

Jose Villarreal

culturally sensitive care

acculturation

documentation status

discrimination

cultural humility