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Mental Health Issues in Work with Immigrants and Refugees

Mental Health Issues in Work with Immigrants and Refugees. Georgi Kroupin, MA,LP Center for International Health, St. Paul, MN. New Americans: Understanding & Working With Their Mental Health Needs. New Americans: Ordinary people under extraordinary stress. New Americans.

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Mental Health Issues in Work with Immigrants and Refugees

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  1. Mental Health Issues in Work with Immigrants and Refugees Georgi Kroupin, MA,LP Center for International Health, St. Paul, MN

  2. New Americans: Understanding & Working With Their Mental Health Needs New Americans: Ordinary people under extraordinary stress

  3. New Americans • Pull immigration • Push immigration • We mostly deal with the Push immigrants/refugees who experience stress on multiple levels

  4. People balancing loss and gain:living through Opportunities • For many – basic safety and security • For some (seniors, handicapped people, women) more possibilities for independence and self-sufficiency • Freedom or communication/information

  5. People balancing loss and gain:living through Internal Losses (individual) • Loss of Ease of Communication • Loss of Independence and Self-Sufficiency • Loss of Security and Stability

  6. People balancing loss and gain:living through Environmental losses (individual) Negative Response: • Feeling that life was useless • Difficulty finding your niche in the future • Acculturation difficulties • Hopelessness about the future

  7. People balancing loss and gain:living through Opportunities • Perspective of gain of material possessions • Opportunities for learning • Opportunities for cultural development for those who were denied their culture • Access to social services for those who need assistance

  8. People balancing loss and gain:living through Environmental losses (individual) • Loss of Material Possessions • Loss of Value of Education and Professional Experience • Loss of Roots and Connection to Cultural and Social Traditions • Loss of Connection to Family and Friends

  9. People balancing loss and gain:living through Opportunities • For those who were denied them, gain of basic civil rights • For those who were denied it - may be an opportunity to find their cultural identity

  10. People balancing loss and gain:living through Internal Losses (individual) Negative Response: • Feeling powerless, unable to control or even predict future • Lack of trust in the system • Isolation and Confusion • Overuse and Pressure

  11. People balancing loss and gain:living through Internal Losses (individual) • Loss of Status • Loss of Self-Esteem and Personal Identity

  12. People balancing loss and gain:living through Internal Losses(individual) Negative Response: • Drinking/Drugs/Gambling • Family abuse • Adultery • Mental Health problems • Physical illness

  13. Irreversible loss and hope for the future • Many refugees have experienced irreversible loss • Many also show incredible resilience • They may be able to learn how to live with loss and still have hope • We need to learn how to tolerate ambiguity and deal with balancing both parts at once

  14. People balancing loss and gain:living through Refugee family with a sick child:Angry father Mother Father Social worker MD Pediatrician Daughter 16 Occupational therapist Daughter 2.5 Son 6 Son 12 Nurse Physical therapist Interpreter

  15. From DSM-I to DSM-IIIR: From symbols to signs • In Biomedicine diseases are largely biological in nature • Disease entities are empirical and universal • They are “discovered” and then described in increasingly full terms

  16. From DSM-I to DSM-IIIR: From symbols to signs Pre-DSM period • 1840 – “idiocy and insanity” • 1880 – “mania, melancholia, monomania, paresis, dementia, dipsomania and epilepsy” • 1917 – American Medico-psychological Association: uniform statistics for hospitals. Revised in 1934 • Revised by the Veterans Administration and the Navy during and after WWII (W. Menninger)

  17. From DSM-I to DSM-IIIR: From symbols to signs • Mental Hospital Service of the American Psychiatric Association published DSM-I • The hallmark of DSM-I is the idea of “reaction” • Symptoms as symbolic statements of underlying problems

  18. From DSM-I to DSM-IIIR: From symbols to signs • 1968 – DSM-II • Stepped away from the idea of psychobiosocial conceptions of mental disorders and dropped the label of “reactive” • Retained the idea that mental illnesses are symbolic expressions of hidden psychological realities

  19. From DSM-I to DSM-IIIR: From symbols to signs • DSM-III and IIIR: from symbols to symptoms • Atheoretical and descriptive • Term “neurosis” dropped as concealing ethiological explanations • Intentional move away from psychological understanding of mental disorders • A clear step toward the exclusive use of biological ethiological models • Biological model was believed to be more scientific and more mainstream in terms of medicine

  20. From DSM-I to DSM-IIIR: From symbols to signs • DSM-IIIR: identification of symptoms is transformed an interpretation of symbols of distress into a reading of signs of disease • Away from psychosociocultural context • Biological discourse replaces an existential, phenomenological one • The afflicted are represented in a purely biological discourse: Schizophrenic replaced by a person with schizophrenia

  21. From DSM-I to DSM-IIIR: From symbols to signs • Classifications of mental disorders (DSM-IIIR, IV) reflect a momentum in a cultural historic process • Psychiatric classifications may be seen as historical and semantic processes, not “things”

  22. From DSM-I to DSM-IIIRGaines (1992) • In Northern Germanic (Protestant) tradition self is “egocentric” • It is the locus of action, thought and emotion • Self is distinct, autonomous and capable of control and it is a source and center of motivation • Social and natural worlds are independent of self and ideally are subject to the actions of self • Individual is believed of literally making him or herself • Individuation and personal development/growth are central popular and professional issues

  23. From DSM-I to DSM-IIIRGaines (1992) • Centrality of notion of “self-control” in the Germanic tradition (and DSM III+) • Ideal self is the one of “self-mastery” • “Out-of-control” states are seen as “pathological” • Treatment is designed to assist regaining the ideal of control

  24. From DSM-I to DSM-IIIRGaines (1992) • The notion of self as responsible for (self) control is a central concept guiding clinical practice • Clinicians interpret patients without this (unconscious) motivation as “not trying”, “unconcerned about their condition”, “not taking care of themselves”, “not involved in their own treatment” (lack of “agency”) • It may result in problematic patient/provider interactions

  25. From DSM-I to DSM-IIIRGaines (1992) • Mediterranean self is “sociocentric” • Self concept incorporates other persons • Individual character is partially determined by “related others” (family, “people”) • Self is dependent on the environment and is not completely under self’s control • Self is a dependent social construct, not an independent psychological one

  26. New Americans:Building a working relationship • Establish rapport • Acknowledge stress and loss • Access strengths and opportunities • Encourage their initiative

  27. Refugee Families balancing challenges and opportunities: adaptation Refugee family with a deaf second wife First wife/mother 55 Husband 65 IP: Second wife 40 MD Son 26 Son 22 Daughter 20 Son 18 . Daughter 16 DHH Advocate Child protection Police Family Therapist

  28. Cultural issues in providing care • There are barriers in our work that are related to cultural differences and there are other obstacles that may look as such • We need to differentiate between the two

  29. Cultural issues in providing care • We often need to accept our cultural incompetence • We are more similar than different • Being different can be an advantage • We can use both similarities and differences to learn, understand, build trust, and help

  30. Cultural issues in providing care Refugee family with a sick child:An accident Mother Father Psychologist Midwife Son 7m.o. Nurse Child Protection Physical therapist Interpreter

  31. Balancing incompetence and skill: collaboration Aspects which are frequently cultural • Explanatory models of problems • Manifestations of mental health problems • Communicating mental health problems • Understanding/accessing social and MH services • Communication and decision making patterns among family-client/patient-helping professional • Cultural acceptability of solutions

  32. Balancing incompetence and skill: collaboration Assessment: • Most of existing instruments are not translated • Issues with construct validity: many Western concepts do not exist in other cultures • Issues with other validity: mental health problems are manifested differently in different cultures • There are major practical limitations: literacy, educational level, etc.

  33. Balancing incompetence and skill: collaboration Barriers, which masquerade as cultural • Communication problems on part of helping professionals • Language barrier, poor use of interpreters • Frank disagreement of clients and their families with professional recommendations  • Common histories of trauma, loss, political or war violence

  34. Language, Culture and Psychopathology Westermeyer & Janca (1997) Language and Cultural issues in MH • Denotation • Connotation • Equivalence in translated materials • Specificity of terms • Reporting threshold in relation to symptom severity

  35. Language, Culture and Psychopathology Westermeyer & Janca (1997) Translation of mental health assessment instruments • Translation by a team of bilingual persons • Back translation by one or more persons not familiar with the original version • Analysis of the three versions • A pilot study in the target population • Reevaluation of the pilot study data

  36. Cultural issues in providing care Refugee family with a sick child:An accident Mother Father Psychologist Midwife Son 7m.o. Nurse Child Protection Physical therapist Interpreter

  37. Balancing incompetence and skill: collaboration Issues related to our culture • Our cultural push to explain, understand • Our cultural push to prepare, be in control • Our difficulty to accept irreversible loss • Our guilt reaction • Our tendency to trust rules more than feelings

  38. Balancing incompetence and skill: collaboration • Working with other cultures gives us an opportunity to look at our culture • Often we assume that we are “normal” and they are “cultural” • Understanding our own culture and working with equally important • The fact that our culture represents the system may not mean it’s “normal”

  39. Balancing incompetence and skill: collaboration What do we do? • Try to separate “cultural” issues from other problems • Use professional interpreters whenever possible • Look at yourself and you will find both differences and similarities • Use both similarities and differences to learn, understand, connect, develop trust, and help

  40. New American Families and Social Systems Refugee family with a dying mother Mother Father MD Nurse Son 48 Son 42 Son 40 . Patient advocate Nurse Nurse Psychologist Chair of Ethics Committee

  41. Clinical strategies • Three most important components of successful cross-cultural care: • Rapport • Rapport • Rapport

  42. Clinical strategies Effective ways of establishing rapport: • Developing curiosity • Deconstructing therapy • Working with “resistance” • Accessing non-verbal dimensions of your encounter • Accepting and utilizing your cultural incompetence

  43. Applying clinical strategies • We can be competent in other dimensions of our encounter to compensate for incompetence in certain dimensions (reality check, metacommunication)

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