The Massachusetts General Hospital Textbook on Diversity and Cultural Sensitivity in Mental Health Second Edition Current Clinical Psychiatry

Current Clinical Psychiatry Series Editor: Jerrold F. Rosenbaum

Ranna Parekh Nhi-Ha T. Trinh Editors The Massachusetts General Hospital Textbook on Diversity and Cultural Sensitivity in Mental Health Second Edition Current Clinical Psychiatry

Series Editor Jerrold F. Rosenbaum Department of Psychiatry Massachusetts General Hospital Boston, MA, USA Current Clinical Psychiatry offers concise, practical resources for clinical psychiatrists and other practitioners interested in mental health. Covering the full range of psychiatric disorders commonly presented in the clinical setting, the Current Clinical Psychiatry series encompasses such topics as cognitive behavioral therapy, anxiety disorders, psychotherapy, ratings and assessment scales, mental health in special populations, psychiatric uses of nonpsychiatric drugs, and others. Series editor Jerrold F. Rosenbaum, MD, is Chief of Psychiatry, Massachusetts General Hospital, and Stanley Cobb Professor of Psychiatry, Harvard Medical School.

More information about this series at http://www.springer.com/series/7634 Ranna Parekh • Nhi-Ha T. Trinh Editors

The Massachusetts General Hospital Textbook on Diversity and Cultural Sensitivity in Mental Health

Second Edition Editors Ranna Parekh Nhi-Ha T. Trinh American Psychiatric Association Harvard University Arlington, VA Boston, MA USA USA

ISSN 2626-241X ISSN 2626-2398 (electronic) Current Clinical Psychiatry ISBN 978-3-030-20173-9 ISBN 978-3-030-20174-6 (eBook) https://doi.org/10.1007/978-3-030-20174-6

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Ranna Parekh and Nhi-Ha T. Trinh Foreword: Staying the Course During Times of Upheaval

Five years have passed since the previous edition of this book was released, but in some ways, it seems like a lifetime ago. It is one of the great paradoxes of this moment in history that even as we in the medical community are making ever-greater strides toward understanding what it means to be culturally competent care providers, some people—leaders and citizens alike—want to go back to a time with less diversity and more divisions. They see our nation’s diversity as a threat, not an asset. This dangerous perspective threatens our society, our healthcare system, and the mental health of the patients we serve. It is certainly a serious setback that adds an extra layer of weariness and concern for mental health providers both seasoned and in training. And it underlines the importance of the message of this book. Its goal is more critical than ever. In 2014, I was rounding into my fifth year as chief diversity officer at the Association of American Medical Colleges. We had started to move past seeing diversity as a problem to be fixed to the realization that inclusion could serve as a solution to some of the most intractable issues in our healthcare system. Cultural competence had emerged as an important metric by which healthcare providers of all types are evaluated. Medical schools and residency training programs were making strides toward embracing diversity and inclusion to improve healthcare, advance health equity, and ensure effective and compassionate care for all patients, regardless of race, culture, gender, or sexual orientation. We had a long way to go, but many of us—myself included—saw positive signs that we were on the right track. However, since the run-up to the 2016 US presidential election, both the scholarly and popular presses have reported that increasing numbers of Americans—many of whom belong to the groups discussed in the chapters of this book—feel increasingly unwelcome, worried, and anxious due to the increasingly xenophobic, divisive, and vitriolic nature of public discourse in this country. The acts of violence and aggression toward racial, cultural, and gender minorities are on the rise. The healthcare system—and particularly mental health facilities—should be a refuge immune to this toxin. Patients of all races, ethnicities, genders, and countries of origin should have their unique needs, perspectives, and experiences understood whenever they interact with the healthcare system. Indeed, this is a necessary ingredient for quality care and a prerequisite for health equity.

vii viii Foreword: Staying the Course During Times of Upheaval

And it is arguably even more important when diagnosing and treating mental illness.

Twin Tenets of Cultural Competence

Throughout my career, I have worked to advance diversity and inclusion among health professionals and in our healthcare system. I firmly believe that a more diverse healthcare work force is a necessary step toward health equity and opens the way for more compassionate and culturally competent care for all patients. But truly embracing diversity, inclusion, and cultural competence goes beyond training providers from diverse backgrounds to “care for their own.” It requires ensuring that providers of all backgrounds have the skills and awareness to care for patients of all backgrounds. Health professionals must make the effort to understand where people come from, the experiences they bring, and the experiences they expect to have. As American society becomes increasingly diverse culturally, ethnically, racially, and linguistically, we in medicine see twin tenets of cultural competence. First is the recognition that patients’ social and cultural influences affect their perceptions of and reactions to health, illness, and medical care. Second is the realization that providers must tailor their care appropriately based on the patient’s unique set of cultural needs and sensitivities. Cultural competence also recognizes that no one exists in a cultural vacuum, including healthcare providers. Culturally competent healthcare providers have learned to acknowledge and examine the potential for unconscious bias that exists within all humans. We are all prone to making snap judgments or assumptions about people based on their superficial and group characteristics—unless we make a conscious effort to avoid them. The beauty of this nation lies in the assimilation of values, not of cultures. We are not a melting pot so much as a rich mosaic of diverse and varied backgrounds, experiences, hopes, and dreams, tied together by a freedom to express our unique selves. Cultural competence helps create the space for that to happen. As in so many aspects of life, communication is the key. This goes beyond words to include actions, attitudes, and how we relate to patients. Culturally competent providers communicate sensitively and, without judgment, treat each person as the unique individual they are. They get to know patients, demonstrating their concern and compassion and—above all—explore the unconscious assumptions that might affect interactions. In other words, the goal of reading this book and receiving cultural competency training in other ways should not be to help you make assumptions about your patients’ lived experiences but to listen to them more effectively— really listen to what they tell you about their own beliefs and experiences every day—in every encounter. We take important steps to understand how individuality (which includes race, culture, gender identify, and country of origin) influences healthcare needs when we take time to recognize subtle Foreword: Staying the Course During Times of Upheaval ix

differences among us. For example, we can better meet the needs of all people when we do not lump all Asians, all Latinos, or all LGBT individuals into one category, no matter how culturally sensitive we are to that category. That is the true goal of cultural competency: listening, caring, and considering our individual experiences while building on the many commonalities we as humans share. You will not achieve this goal by reading a single textbook or sitting in on a training. Rather, it’s a lifelong pursuit with a mind-set to “open.” Are you up to the challenge? Marc Nivet UT Southwestern Preface

It’s human nature to try to understand why distressing symptoms are occurring, such as sleep loss, anxiety, or thoughts of suicide, and to associate them with environmental or temporary circumstances, such as job stress or grief, when explaining to healthcare providers how they feel it’s important to most patients to provide that context for symptoms. Context can include changes from baseline levels of functioning, events surrounding the onset or exacerba- tions of symptoms, and associated psychosocial difficulties such as family or financial problems. The filters through which patients interpret their symptoms will determine which they report and how severe they are perceived. Culture defined broadly as a set of beliefs stemming from one’s family, social, or national origin reference group also provides a context for how people interpret psychological, emotional, behavioral, and psychiatric symptoms. However, most people would not understand the importance of sharing such an explanation with clinicians when seeking help for their distress. Understanding cultural differences, listening for subtle cultural interpretations of symptoms, and knowing when to ask about them can guide clinicians’ queries during diagnostic interviews and discussions around potential treatments, thus improving the quality of care. The second edition of The Massachusetts General Hospital Textbook on Diversity and Cultural Sensitivity in Mental Health provides culturally based conceptual frameworks and in-depth information on epidemiology, symptom presentations, and social contexts of mental illness in racial and ethnic groups, gender minority populations, and immigrant groups. Guidelines are provided for conducting patient interviews that reach beyond surface symptoms and help the clinicians avoid the mistake of relying on their personal cultural references as filters in clinical decision-making. The breadth of topics makes this collection broadly useful by a range of practitioners—medical, legal, mental healthcare, and journalistic. The editor’s careful selection of contributors reflects the view that professionals from a variety of disciplines can play a role in presenting to the public, especially those in need, a compassionate and unbiased representation of mental health that demonstrates an appreciation of individual differences. In Chapter 1, guidelines are provided for training in cultural competence and implicit bias, including strategies for dealing with resistance. The methods for skill development, reshaping thinking patterns, and increasing self-awareness are provided as well as ways to address sensitive issues, such as privilege, white fragility, and coming to terms with one’s own racism. The

xi xii Preface authors discuss challenges unique to vulnerable groups at the intersectionality of characteristics, such as race and gender or age and socioeconomic status. Chapter 2 describes the value of cultural humility as an approach to interview patients. Humility is reflected in a posture of appreciation for differences among people and in the sincere desire to better understand those differences. Specific guidance is provided for ways to augment clinical interviews to gain a clearer understanding of how a person’s cultural reference for health problem and treatment influences their interpretation of symptoms. Chapters 3 and 5 provide insights from beyond the realm of mental healthcare. Chapter 3 on mediation and negotiation recognizes how men and women across the age spectrum differ in their comfort with asserting their will in these processes. As authors Hoffman and Triantafillou explain, “cultural competence involves more than freeing our minds of bias—it requires affirmatively seeking to understand the people we encounter in the mediation process and elsewhere.” Guidance is offered for creating an comfortable atmosphere in the negotiation and mediation process for people from various demographic and cultural groups. Similarly, Chap. 5 on news reporting of mental health issues, especially in controversial circumstances such as mass shootings, provides guidance for cultural sensitivity and compassion in reporting. Excellent examples are included of how journalism has handled stories on mental health and how journalists have attempted to provide information about race and mentally illness that transcends stereotypes. Chapters 4, 6, and 13 cover factors that can limit access to and use of medical care in immigrant populations beyond obvious language differences, such as stigma attached to mental illness and fear or mistrust of healthcare systems. The readers are provided with ways to evaluate how their own culture influences their approach to patient care. The authors emphasize the importance of considering broader issues of power, privilege, and structural inequality when working with migrant communities and advocate for cultural responsivity and intervention at the organizational, structural, and patient levels. Chapters 7 through 11 are excellent reference chapters on mental health presentation, treatment, and sociocultural factors in health for specific populations, including people of African descent, American Indians, Alaska Natives, Arab Americans, Asians, and Latinos. Appreciation of how conceptualizations of mental health and illness vary across these groups can improve the accuracy of psychiatric diagnoses, the treatment selection, and the discussion of sensitive mental health issues with patients and their family members. Chapter 12 provides a conceptual framework for working with people on the sexual and gender continuum. It encourages clinicians to think beyond binary labels and to consider gender identification, gender role and expression, sexual attraction, and sexual behavior as elements of sexual and gender identity. In their discussion of health problems unique to sexual minority populations, the authors encourage attention to the intersectionality with age, race, and socioeconomic status. Preface xiii

The chapters of this book focus primarily on mental health. However, it is an excellent reference book for clinicians in training across other areas of medicine. Guidance is provided for those who work in psychiatric settings, particularly those that serve multicultural communities, but is also applicable to those working elsewhere in the healthcare system. The authors effectively make the case that a richer understanding of differences across cultural groups can enhance the quality of care provided and the healthcare experiences of those in need. This guide for culturally sensitive and competent diagnostic evaluations and patient interactions sets the stage for developing strong therapeutic alliances and efficacious treatment plans. Monica Ramirez Basco, PhD Adjunct Associate Professor Psychiatry University of Texas Southwestern Medical Center Former Assistant Director of Neuroscience, Mental Health and Broadening Participation White House Office of Science and Technology Policy Quotation Page

“Darkness cannot drive out darkness: only light can do that. Hate cannot drive out hate: only love can do that.” Martin Luther King, Jr.

xv Acknowledgments

The editors would like to thank the chapter authors for their contributions— their commitment to cultural competency is evident in both their writing and work. We appreciate the Springer Publisher team, especially Ms. Gina Kahn and Ms. Nadina Persaud, for the opportunity to edit a second edition to the 2014 The Massachusetts General Hospital Textbook on Diversity and Cultural Sensitivity in Mental Health—their guidance has been invaluable. Additionally, we would like to thank both Marc Nivet, EdD, MBA, and Monica Ramirez Basco, PhD, for reviewing our textbook and providing insights from their multiple professional lenses in the Foreword and Preface, respectively. Finally, we want to recognize Jerrold Rosenbaum, MD, the textbook’s series editor and chair of the Psychiatry Department at Massachusetts General Hospital/Harvard Medical School. Jerry, thank you for your support and mentorship—their involvement inspired excellence.

xvii Contents

Part I Innovative Ways to Understand Diversity

1 Diversity Dialogue �� 3 Anne Emmerich, Ariel Otero, Ranna Parekh, and Estee Sharon 2 The Engagement Interview Protocol (EIP): Improving the Acceptance of Mental Health Treatment Among Culturally Diverse Populations �� 25 Nhi-Ha T. Trinh, Trina Chang, and Albert Yeung 3 Cultural and Diversity Issues in Mediation and Negotiation �� 37 David Alan Hoffman and Katherine Triantafillou 4 Providing Medical Care to Diverse Populations �� 55 Deborah Washington and Robert Doyle 5 Cultivating Courage, Compassion, and Cultural Sensitivity in News Reporting of Mental Health During Challenging Times �� 75 Linda R. Zucker 6 Illegal, Alien, and Other: Cultural Competency and Migration �� 91 Schuyler W. Henderson

Part II Specific Populations

7 Psychiatry for People of African Descent in the USA ��105 Carl Bell and Christine M. Crawford 8 American Indian and Alaska Native Mental Health ��127 Joseph E. Trimble, Jeff King, Teresa D. LaFromboise, and Dolores Subia BigFoot 9 Mental Health of Arab Americans: Cultural Considerations for Excellence of Care ��149 Imad Melhem, Zeina Chemali, and Ashlee Wolfgang

xix xx Contents

10 An Approach to Mental Health in Asian Americans ��175 Shirin N. Ali 11 Cultural Sensitivity: What Should We Understand About Latinos? ��201 Aida L. Jiménez, Margarita Alegría, Richard F. Camino-Gaztambide, Lazaro V. Zayas, and Maria Jose Lisotto 12 Not by Convention: Working with People on the Sexual and Gender Continuum ��229 Jeremy A. Wernick, Samantha M. Busa, Aron Janssen, and Karen Ron-Li Liaw 13 Understanding the Mental Health of Refugees: Trauma, Stress, and the Cultural Context ��253 B. Heidi Ellis, Jeffrey P. Winer, Kate Murray, and Colleen Barrett Index ��275 Contributors

Margarita Alegría, PhD Disparities Research Unit at Massachusetts General Hospital, Boston, MA, USA Department of Medicine, Harvard Medical School, Boston, MA, USA Shirin N. Ali, MD Department of Psychiatry, Columbia University, College of Physicians and Surgeons, New York, NY, USA Colleen Barrett, MPH Department of Psychiatry, Boston Children’s Hospital, Boston, MA, USA Monica Ramirez Basco, PhD Department of Psychiatry, University of Texas Southwestern Medical Center, Runway Bay, TX, USA Carl Bell, MD Medical-Surgical/Psychiatric Inpatient Unit, Jackson Park Hospital, Chicago, IL, USA University of Illinois at Chicago, Chicago, IL, USA Dolores Subia BigFoot, PhD Department of Pediatrics, Center on Child Abuse and Neglect, University of Oklahoma Health Science Center, Oklahoma City, OK, USA Samantha M. Busa, PsyD Department of Child and Adolescent Psychiatry, NYU Child Study Center, New York, NY, USA Richard F. Camino-Gaztambide, MD Department of Psychiatry, Medical College of Georgia at Augusta University, Augusta, GA, USA Trina Chang, MD, MPH Depression Clinical & Research Program, Massachusetts General Hospital, Boston, MA, USA Harvard Medical School, Boston, MA, USA Partners Population Health, Partners HealthCare, Boston, MA, USA Zeina Chemali, MD, MPH Division of Global Psychiatry, Department of Neurology and Psychiatry, Massachusetts General Hospital-Harvard Medical School, Boston, MA, USA Christine M. Crawford, MD, MPH Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA Harvard Medical School, Boston, MA, USA

xxi xxii Contributors

Robert Doyle, MA, DDS, MD Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA B. Heidi Ellis, PhD Department of Psychiatry, Boston Children’s Hospital/ Harvard Medical School, Boston, MA, USA Anne Emmerich, MD Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA Schuyler W. Henderson, MD, MPH Department of Clinical Psychiatry, New York University, New York, NY, USA Department of Child and Adolescent Psychiatry, Child Study Center, Bellevue Hospital, New York, NY, USA David Alan Hoffman, BA, MA, JD Boston Law Collaborative, LLC, Boston, MA, USA Harvard Law School, Cambridge, MA, USA Attorney and Mediator, Cambridge, MA, USA Aron Janssen, MD Pritzker Department of Psychiatry and Behavioral Health, Ann and Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL, USA Aida L. Jiménez, PhD Department of Psychology, University of Puerto Rico, San Juan, PR, USA Jeff King, PhD Department of Psychology, Western Washington University, Bellingham, WA, USA Teresa D. LaFromboise, PhD Graduate School of Education, Stanford University, Stanford, CA, USA Karen Ron-Li Liaw, MD Department of Child and Adolescent Psychiatry, NYU Child Study Center, New York, NY, USA Maria Jose Lisotto, MD Department of Psychiatry, McLean Hospital, Belmont, MA, USA Harvard Medical School, Boston, MA, USA Imad Melhem, MD Neurobehavioral Medicine Consultants, Saint Clairsville, OH, USA Kate Murray, PhD, MPH School of Psychology and Counselling, Queensland University of Technology, Brisbane, QLD, Australia Ariel Otero, MD Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA Ranna Parekh, MD, MPH American Psychiatric Association, Arlington, VA, USA Estee Sharon, PsyD Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA Contributors xxiii

Katherine Triantafillou, BS, JD, MPA Attorney and Mediator, Cambridge, MA, USA Joseph E. Trimble, PhD Department of Psychology, Western Washington University, Bellingham, WA, USA Nhi-Ha T. Trinh, MD MPH MGH Depression Clinical & Research Program, Massachusetts General Hospital, Boston, MA, USA Harvard Medical School, Boston, MA, USA Deborah Washington, PhD, RN Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA Jeremy A. Wernick, LMSW Department of Child and Adolescent Psychiatry, NYU Child Study Center, New York, NY, USA Jeffrey P. Winer, PhD Department of Psychiatry, Boston Children’s Hospital/Harvard Medical School, Boston, MA, USA Ashlee Wolfgang, PsyD Counseling and Psychological Services, Carnegie Mellon University, Pittsburgh, PA, USA Albert Yeung, MD, ScD Depression Clinical & Research Program, Massachusetts General Hospital, Boston, MA, USA Harvard Medical School, Boston, MA, USA South Cove Community Health Center, Boston, MA, USA Lazaro V. Zayas, MD Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA Linda R. Zucker, BA, MBA, JD National Coalition of Independent Scholars, Walla Walla, WA, USA Part I Innovative Ways to Understand Diversity Diversity Dialogue 1 Anne Emmerich, Ariel Otero, Ranna Parekh, and Estee Sharon

Introduction a time of turmoil and fear for many Americans, particularly those from minority and immigrant In professional life, the concept of cultural differ- communities. Public outrage over the killing of ence can take many forms. Each day an individual unarmed black men and women, such as Michael encounters people who differ in age, ethnicity, gen- Brown in Ferguson, Missouri, and Rekia Boyd in der identity, health status, housing status, language, Chicago, led to protest marches and the rise of nationality, race, sexual identity, socioeconomic the Black Lives Matter and Say Her Name move- status, weight, etc. As a professional, one may be ments [2]. The incidence of hate crimes increased confronted with experiences with cultural themes, during the weeks after the presidential election in some of which may be uncomfortable to discuss. November 2016 (although remained lower than Diversity Dialogue was first introduced to the their height in 2001) [3] and some hate groups public in the 2014 first edition of this book, in a have felt more comfortable expressing racist sen- chapter titled “Diversity Dialogue: An Innovative timents publicly, sometimes with violent out- Model for Diversity Training” [1]. Since the pub- comes such as in Charlottesville, Virginia in lication of the first chapter, conversation about August, 2017 [4]. diversity issues in the United States has become The polarization of society has also been more heated and the need for every member of accompanied by an increase in the number of society to have cross-cultural communication people engaging in political activism. The April skills more urgent. The transition of power from 2018 Washington Post/Kaiser Family Foundation President Barack Obama, the first black President, Survey on Political Rallygoing and Activism [5], to President Donald Trump, in January 2017, was which involved 1850 US adults, indicated that one in five Americans had participated in a rally A. Emmerich (*) during 2016/2017 and 20% of those had done so Department of Psychiatry, Massachusetts General for the first time. There has been growing recog- Hospital, Harvard Medical School, nition of the value of white people acknowledg- Boston, MA, USA ing and understanding their own culture as a e-mail: [email protected] mechanism to address racial disparities in all A. Otero · E. Sharon areas of American life. Workshops about white Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA privilege are now commonly offered at churches and community centers such as the program R. Parekh American Psychiatric Association, “White Privilege, Let’s Talk” of the United Arlington, VA, USA Church of Christ [6].

© Springer Nature Switzerland AG 2019 3 R. Parekh, N.-H. T. Trinh (eds.), The Massachusetts General Hospital Textbook on Diversity and Cultural Sensitivity in Mental Health, Current Clinical Psychiatry, https://doi.org/10.1007/978-3-030-20174-6_1 4 A. Emmerich et al.

Diversity Dialogue is an initiative that grew aspect of the patient-doctor relationship. out of the work of the Department of Psychiatry Hospitals are traditionally hierarchical systems in Center for Diversity (formerly called Diversity which power differentials have been accepted as Committee) at MGH. This group was formed in part of the institutional culture (doctor/nurse, 1997 and has included more than 60 multidisci- doctor/patient, attending/trainee, trainee/student, plinary members of the department, which itself business manager/doctor, etc.). By allowing dis- reaches approximately 800 faculty, trainees, and cussion of often unspoken feelings with a diverse administrative staff. The Center focuses on group of coworkers, Diversity Dialogue offers an recruitment, retention, and promotion of faculty opportunity for individual members of the team and trainees from underrepresented minority to feel more comfortable acknowledging uncer- groups and on educational offerings for the hos- tainty and listening to other perspectives. pital and wider community. In 2010, the Center for Diversity was approached to conduct diversity training for a Diversity: Equity and Inclusion student mental health clinic serving a culturally and economically diverse population of college Diversity Dialogue, as conceived and imple- students and faculty. A series of discussions was mented by the MGH Department of Psychiatry held with the requesting clinic, and it was learned Center for Diversity, is conducted in healthcare that prior diversity trainings using a didactic settings. However, the tools used can be applied model focused on clinical competence were not to other settings. To understand the context of as effective as expected. Drawing from the expe- this work, this chapter reviews historical devel- riences of peer learning and story sharing in opments of diversity initiatives in the wider monthly Center meetings, it was decided a new United States such as the corporate world and approach was needed and Diversity Dialogue educational institutions as well as healthcare was created. systems. Since 2010, Center members have conducted Diversity Dialogue with approximately 400 healthcare professionals including mental health Diversity Initiatives in the United clinicians, medical specialty professionals, psy- States chiatry residents, allied health professionals, medical students, hospital administrators, and Workplace diversity initiatives in the United support staff. The mission is to offer a profession- States arose out of the cultural and legislative ally facilitated opportunity for those working in changes of the 1960s. Corporate concern about healthcare settings to share personal stories and lawsuits in the wake of the Equal Pay Act of 1963 experiences with the goal of enhancing the skills and the Civil Rights Act of 1964 led to the devel- needed for effective cross-cultural communica- opment of training classes that focused on impart- tion and improved patient care. ing the “nuts and bolts” of these legislative Diversity Dialogue is built on the tenet of cul- actions. In their article, A Retrospective View of tural sensitivity (as opposed to trainings that Corporate Diversity Training from 1964 to the focus on cultural competence) and emphasizes a Present [7], Anand and Winters discuss the philosophy of inclusion, respect, and acceptance change in focus of diversity trainings in the work- of otherness. Our core value is awareness of the place throughout the last 50 years: compliance in unique elements that each individual’s cultural the 1970s, assimilation in the early 1980s, foster- and professional background brings to the con- ing sensitivity between 1980 and the late 1990s, versation. When done with groups who are them- and creating inclusive workplaces from 2000 selves heterogeneous in terms of job titles, onward. Diversity Dialogue allows participants an experi- At the time of publication of our initial chap- ence of the reordering of power, an inherent ter on Diversity Dialogues, research on the 1 Diversity Dialogue 5 effectiveness of diversity trainings in the United ducted over a significant period of time.” Their States was limited and discouraging. In the review found that the proportion of women in a intervening years however, new research has training group was positively associated with been published and is beginning to differentiate more favorable reactions to diversity training. specific aspects of diversity training which can They found no effect on training outcomes based make a difference. on whether training was mandatory or voluntary In an article titled A meta-analytical integra- and also found no effect based on whether train- tion of over 40 years of research on diversity ing was group-specific (for instance, if training training evaluation [8], Bezrukova et al. note was for a group entirely consisting of LGBT indi- “while many of the diversity training programs viduals) or inclusive (if the training group fell short in demonstrating effectiveness on some included a mix of LGBT and heterosexual par- training characteristics, our analysis does reveal ticipants) [8]. that successful diversity training occurs.” They Lindsey et al. [10] studied the impact of two start their article by citing the work of many prior specific diversity training exercises on under- authors, pointing out that earlier diversity train- graduate students. In one study, looking at the ing research has fallen mainly into two areas: impact of perspective-taking, 118 students were asked to write a few sentences imagining the 1. Research looking at diversity trainings using challenges faced by LGBT or racial minority psychological diversity theory as a starting people. The study showed an increase in pro- point, specifically Alport’s contact hypothesis diversity attitudes and behavioral intentions [9] which theorizes that putting people of toward these groups which persisted 8 months opposing views together will help them to later. In another study, 158 students were asked to understand and treat each other better. set a personal, measurable goal at the end of a 2. Organizational research which has focused diversity training. Results showed an increase in on the context and delivery of diversity train- pro-diversity behaviors at 3 months and improved ing such as where training occurs (school, pro-diversity attitudes at 9 months. The authors work, community), how training is reinforced commented on the role of personality traits and over time, and how motivated learners are for suggested that perspective-taking might make the training. This line of research has led to less of an impact on people who are already interest in multimodal trainings [8]. highly empathic [10]. They also suggested that people who have high social dominance orienta- Bezrukova’s group analyzed 260 out of 2000 tion traits tend to be more resistant to diversity diversity training reports found in the literature. trainings and that the presence of a respected Their analysis found a statistically significant authority figure who endorses the training can training impact on cognitive learning (becoming increase the effectiveness of training for partici- aware of issues such as microaggression) which pants with these traits [10]. remained stable or increased over time. They Bleich, in an article titled The different types theorized that this might be due to cognitive of diversity training that work [11] says “when it learning being reinforced by news articles, books, works, diversity trainings make employees feel and personal experiences which would trigger included and part of a common effort.” Bleich participants to remember the cognitive informa- cites business reasons for organizations engag- tion they learned in the training. They found a ing in diversity efforts, including greater reten- less robust impact on attitudinal/affective learn- tion of employees and reduced cost due to ing which appeared to decay over time. They also employee turnover. Another factor cited is that concluded “the positive effects of diversity train- companies that value diversity have been shown ing were greater when training was comple- to have increased sales and profits compared to mented by other diversity initiatives, targeted to other companies. Citing a number of prior stud- both awareness and skills development, and con- ies, Bleich offers five factors that contribute to 6 A. Emmerich et al. successful diversity training initiatives: creating tional learning, leads to increased self-awareness common goals; confronting unconscious bias; and alteration of perspectives [7]. Single-loop focusing on inclusion; conducting a training learning is the least difficult and most familiar needs assessment; and moving away from pro- approach. Double loop requires the discipline to hibitive language (encouraging workers to measure and follow-up. Triple loop is the most choose a workplace that values diversity rather difficult and elusive. It requires the above and than requiring it). Bleich concludes “diversity both trained and skilled facilitators who are pas- training that presents diversity acceptance as a sionate, energetic, and self-aware enough to choice that benefits everyone in the workplace allow the participants to direct much of the dis- results in positive returns that last longer.” Bleich cussion. Anand and Winters [7] theorize that also suggests using tools such as gamification, many workplace training programs that have microlearning and mobile learning to engage failed to lead to any kind of change fall into the workers in diversity learning [11]. single-loop category. In looking at whether diversity trainings are In addition to the many academic and organi- successful in any given organization it is impor- zational studies on diversity initiatives, there tant to consider what measure of success the exists a robust online body of literature on the organization is using. The reasons an individual topic. In an article titled Must-Read Articles on employer might offer or require diversity training Diversity in the Workplace: Valuable Insights on can vary from merely wanting to appear to care the Challenges, Benefits, and Best Practices for about diversity to more deeply held commitments Cultivating Diversity [14], Angela Stringfellow such as increasing diversity in the workplace, offers a short synopsis and three “take home” better understanding clients’ needs or even points for each of a variety of articles that cross becoming an agent for change in the community. the spectrum from fully supporting workplace Ross, in his book Re-Inventing Diversity [12], diversity initiatives to questioning the effective- states that “success, unfortunately, is too often ness of these. In this latter category, Stringfellow defined as fewer diversity complaints raised with summarizes an article by Demby [15] who won- human resources and making a half-hearted com- ders whether the term diversity has become mitment to increasing diversity in future hires.” merely a “buzzword” in corporate America and Kalev, Dobbin, and Kelly [13] analyzed data from shares this summary of Demby’s suggestions for 708 private sector workplaces during the time how to change this: period 1972–2002 and determined that “efforts to moderate managerial bias through diversity train- • “Diversity only can be productive when coming and diversity evaluations are least effective at panies put thought into how to invite and increasing the share of white women, black control the resistance against accepted women and black men in management” and sug- norms” [14] gested that the factor that appeared to be most • “Companies need to be prepared to deal effective was the designation of responsibility for with a hefty amount of skepticism when diversity to specific personnel. This enhanced the working toward creating more diverse work- effectiveness not only of diversity training and places” [14] networking programs but also increased the over- • “Companies need to support workers they all diversity of managers [13]. hire when creating a more diverse workforce Anand and Winters [7] propose that a way to because they become representatives of diver- understand diversity trainings is through the con- sity and shoulder much of the resistance and cept of triple-loop learning postulated by Robert pushback themselves” [14]. Hargrove in 1995. Under this theory, single-loop learning teaches skill development, double-loop Demby’s recommendations [15] are important learning tries to reshape thinking patterns, and ones. As representatives of diversity, minority triple-loop learning, also known as transforma- employees often feel neglected. The position of 1 Diversity Dialogue 7 token representative is undesirable to most and are often used interchangeably. Cultural compe- they could benefit significantly from administra- tency implies a tangible and reachable body of tive and peer support to avoid burnout. Diversity knowledge with a finite outcome while cultural Dialogue is an enterprise that both supports and sensitivity suggests ongoing learning with accu- unites a diverse workforce. Most facilitators of mulated skills never reaching a finite end. Given the Diversity Dialogue look forward to the train- the rapidly changing demographics in the United ings and experiences as both deeply fulfilling and States, and patients’ unique interpretations of hopeful. It is an opportunity for representatives of their multiple cultures, cultural sensitivity has minority groups and supportive fellow employ- become the preferred term. ees to come together with the support of the Cultural sensitivity also entails a critical shift administration to work toward a positive goal. in perspectives employed by healthcare professionals. Culturally competent medical care focuses on understanding culture as it refers to Diversity Initiatives in Healthcare patients and their families. Culturally sensitive Settings medical care, however, includes understanding and incorporating the effects of the cultural back- Early focus on cultural competence in healthcare grounds of providers on interactions with, and appeared in the nursing field with recognition interpretations of, patients. In mental health in that the risk of misunderstanding people from particular, providers are the very diagnostic and other cultures could have deadly consequences. therapeutic tools for patients. Hence, awareness The field of transcultural nursing was developed of one’s own cultural and personal biases is criti- by Leininger in the 1950s [16] in response to cal in assessing and treating diverse populations. growing awareness of cultural differences There is a growing body of data that suggests brought forth by a massive increase of immigra- that taking the time and energy to consider the tion. Leininger felt that the learning of specific patient’s culture and its impact on communica- cultural knowledge, such as holidays, traditions, tion can affect clinical outcomes [19, 20]. A non- common cultural missteps, was a necessary com- judgmental approach with the provider ponent of providing competent patient care. acknowledging her ignorance of the patient’s cul- Worried that this approach could result in stereo- ture can provide an opportunity for learning and typing, Ramsden, who worked with Maori building trust. The provider can ask the patient to women in New Zealand, [17] suggested a focus teach her about what is most important to discuss on developing trust in the partnership between and decide together. Despite its apparent simplic- nurse and patient to create “cultural safety” and ity, this clinical tool is an infrequent occurrence designed a framework for analysis of the power in general clinical practice. Allowing the patient relationships between caregivers and patients. to briefly act as a teacher, and the provider as the Simultaneously, in the United States, Campinha- student, decreases power differentials and Bacote [18] developed a model of cultural com- reduces the barriers to communication. petence “in which the health care provider As society becomes more diverse, and as continuously strives to achieve the ability to members of minority communities are increas- effectively work within the cultural context of the ingly becoming healthcare professionals, cross- client” and suggested that “cultural competence cultural encounters in which the clinician is the is the process of becoming, not a state of being.” victim of a racial or cultural insult are more fre- Campinha-Bacote identified five specific ele- quently being documented and openly discussed. ments of this process: cultural awareness, cul- In an article titled When a family requests a white tural knowledge, cultural skill, cultural doctor [21], Kimberly Reynolds describes an encounters, and cultural desire [18]. experience she had as a third year pediatric resi- Despite their distinct connotations, the terms dent when a parent asked her not to touch his “cultural competency” and “cultural sensitivity” child and requested that the child be reassigned to 8 A. Emmerich et al. a white doctor. The article explores the tension Looking back, what I said likely had little impact between the traditional medical ethical principle on Mr. Smith at the moment. However, to this of patient autonomy versus the history of racial day, I believe it had a significant and positive discriminatory practices in medicine in which impact on the female resident who experienced black physicians were marginalized or excluded. numerous incidents of discrimination and The author notes the difficulty institutions grap- mistreatment.” ple with in situations where patients make specific requests regarding their care. For instance, the request by a female patient, who has been the Factors that Impact Cross-Cultural victim of sexual assault, to be examined by a Communication female provider, is not the same as the request of a patient who refuses to be examined by a physi- The meaning of culture is complex and implies cian from another culture due to prejudicial the integrated patterns of human behavior that stereotypes. include thoughts, communications, actions, cus- One of the authors of the current chapter had toms, beliefs, values, and institutions of racial, the following experience as a young attending on ethnic, religious, or social groups. Conversations the teaching service of a residency program with about race and culture are often highly charged predominantly foreign medical graduates. A high and loaded with conscious, subconscious, and proportion were Muslim and from Arabic unconscious biases making them difficult to con- countries. duct in professional settings where they are often “As I was sitting in the nurse’s station, a young most needed. female resident wearing a hijab came to me Evidence-based practices in mental health mildly flushed and on the verge of tears. She was studies rely on well-defined sets of behaviors as supposed to be out pre-rounding on the patients. ultimate outcome criteria. Diversity, however, is I asked her what was wrong. She told me that Mr. fluid. Discussing it tends to bring up hazy feel- Smith refused to speak with her. He loudly called ings and reactions typical to times of confusion. her a terrorist and demanded to speak with an Discomfort that is carefully monitored by leaders American doctor. She tried to reassure him it was and facilitators may be the most meaningful safe to speak with her as his physician. However, place to start a discussion about diversity because Mr. Smith insulted her with multiple racial slurs it enables participants to tap into and express until she left the room. I rose from my chair filled deeper thoughts, attitudes, and biases. Although with indignation and sadness. In particular, this hard to measure, the authors theorize that allow- Muslim female resident was one of the gentlest ing the emergence of confusion, discomfort, and and hardworking physicians I knew. She was the vulnerability while talking about diversity in a mother of three small boys and always had a kind well-contained environment may – in due word or smile on her face. I did not know exactly course – increase one’s adaptability to the rapidly what was said, but I could tell she was deeply changing diversity in our country. shaken. I bolted to Mr. Smith’s room and con- There are a number of factors that can impact fronted him. I asked him what the problem was. cross-cultural communication. Those who wish He told me he would not work with a Muslim to undertake the process of conducting diversity doctor who could be a terrorist. I told him in no dialogues should become familiar with these top- uncertain terms that each and every resident was ics, or should engage experts, to reduce the risk a hardworking, competent, and able physician. I of inadvertently stigmatizing and traumatizing let him know he could decline to work with train- participants who share sensitive personal stories ees, but insults and humiliation would not be tol- and beliefs that others strongly disagree with. erated. He remained indignant but did listen to Facilitators should be aware of the history of rac- what I had to say. The resident remained in the ism in our country and how this impacts everyday room as I completed the whole interview. interpersonal interactions. The term racism is not 1 Diversity Dialogue 9 the same as the term prejudice, for instance, but adulthood to recognize how little she really knew implies an oppressive system of power over oth- about the challenges black Americans face every ers which includes ideological, institutional, day and describes the education she sought to interpersonal, and internalized mechanisms become a racial justice activist. (known as the four I’s of oppression) [22]. It is also critical that facilitators are aware of the wide spectrum of potential responses to cross- Communication Styles cultural dialogue. Despite the name of the training and the reality that its existence suggests In their article 3 Situations where cross cultural there are issues of discrimination, some partici- communication breaks down [26], Toegel and pants may simply disagree or not be aware. It is Barsoux state “the strength of cross cultural important to support and protect participants who teams is their diversity of experience, perspective share an unpopular and less common perspective and insight. But to capture those riches, col- from the majority of the group. An empathetic leagues must commit to open communication; and protected environment for both the ignorant they must dare to share.” They go on to discuss and the expert alike is the goal. three areas in which cultural differences in communication often are evident in the workplace:

Segregation • Differences in participation across cultures with people from egalitarian cultures such as One of the most basic factors impacting cross- the US feeling comfortable voicing their opin- cultural dialogue in the United States is segrega- ions quickly and openly and people from more tion. In 1962 Martin Luther King, Jr., said “I am hierarchical cultures being more hesitant convinced that men hate each other because they [26]. fear each other. They fear each other because • Differences in comfort with public disagree- they don’t know each other and they don’t know ment with people from some cultures viewing each other because they don’t communicate with open conflict as a social failure and people each other, and they don’t communicate with from other cultures viewing it as a sign of each other because they are separated from each deepening trust [26]. other” [23]. Despite growing diversity within • Differences in comfort with giving or receiv- workplace settings, it remains rare for Americans ing feedback [26]. to have personal relationships with people outside of their own cultural group or to live in a diverse neighborhood. The 2017 Fair Housing Privilege Alliance report [24] states “in today’s America, approximately half of all Black persons and 40% Cross-cultural communication is impacted by of all Latinos live in neighborhoods without a privilege differentials among participants. White presence. The average White person lives Privilege refers to the unearned advantages some in a neighborhood that is nearly 80% White. members of a society have over others. The most Persons with disabilities are also often segregated striking example of this in the United States is or prevented from living in their community of racial privilege, starting in the 1600s when the choice, both because a great deal of housing is term “white” began to be associated with legal inaccessible and because they experience high privileges denied to black slaves from Africa levels of discrimination” [24]. compared to indentured servants who were In her book Waking Up White [25], author mainly white Europeans, thus establishing that Debby Irving describes her life experience of even the poorest of white people had privilege growing up in an upper class white community in compared to those whose skin was dark [27, 28]. the 1950s. She shares the process that led her in Other forms of privilege in American society, in 10 A. Emmerich et al. no particular order, include being able-bodied, can recognize when we as educators exhibit these heterosexual, male, wealthy or young. defense modes, when our sense of entitlement In 1988, Peggy McIntosh [29] introduced the based on privilege is challenged.” “invisible knapsack,” a list of 46 everyday ways It is important to note that without training in which she recognized the privilege of her there is no reasonable way to expect the privi- whiteness and said “I have come to see white leged to automatically be aware of their biases. privilege as an invisible package of unearned This is exactly why privilege exists and is diffi- assets that I can count on cashing in each day, but cult to address. The beneficiaries of the unearned about which I was ‘meant’ to remain oblivious. rights and protections do not imagine how they White privilege is like an invisible weightless could be perceived or treated in any other way. knapsack of special provisions, assurances, tools, They are so immersed in it that it is part of every maps, guides, codebooks, passports, visas, moment. To borrow an analogy, the hardest thing clothes, compass, emergency gear, and blank for fish to see is the water [31]. Less kindly, the checks.” McIntosh encourages us all to make our privileged perceive the others as blades of grass own list of the ways in which we have privilege to beneath their feet. They do not wish them harm, increase our awareness of, and sensitivity to, but have been walking on them so long, how those who do not. could that be a problem? In cross-cultural situations such as clinical encounters, members of the privileged culture (however that is defined in that moment) are Intersectionality often oblivious to the ways in which their privilege is impacting the situation. For instance, an Closely aligned with the concept of privilege is able-bodied physician might not think about the the concept of intersectionality, a term first used challenge for a patient in a wheelchair who lives by Kimberlee Crenshaw [32] writing from the alone when told they must do a bowel prep for a perspective of black feminism. This concept colonoscopy. describes the added burden of oppression experi- In an article titled When White Women Cry: enced by many in our society who have more How White Women’s Tears Oppress Women of than one factor that causes them to be marginal- Color [30] scholar Mamta Accapadi discusses ized through processes such as ageism, sexism, the particular tensions that can arise when women racism, classism, anti-LGBTQ prejudice, etc. of various races and ethnicity engage in dialogue Crenshaw’s original description focused on the about cultural issues. While all women share lack experience of black women who suffer oppres- of privilege compared to men in our society, sion, both by being women and by being black, white women have privilege due to their white- whose experiences cannot be evaluated using the ness which might cause them to struggle to framework of white women and oppression due understand issues described by other women. to the inherent difference in privilege of white Accapadi gives the example of a meeting in and black women when facing what might seem which a black woman’s comments about institu- on the surface like similar problems [32]. tional lack of support for women of color cause a white woman to feel she is being attacked and to start crying. The crying derails the discussion, White Fragility causing the black woman to be viewed as having caused a problem rather than her being able to get Among the topics those engaged in facilitating the support she was seeking. Accapadi offers a cross-cultural discussions should be familiar with model for understanding privilege identities is the work of Robin DiAngelo who describes the called PIE (Privileged Identity Exploration tension white people can feel in cross racial con- Model) [30] and says “Perhaps the most effective versations in her book White Fragility, Why It’s use of this model is for self evaluation so that we So Hard for White People to Talk About Racism 1 Diversity Dialogue 11

[33]. DiAngelo offers the perspective that discus- Table 1.1 Cross’ five step black identity development sions about race can trigger an internal good/bad model [34] binary analysis by white people which makes Step Description active discussion of white culture complex. Pre-encounter Individual views majority culture as Understanding that racism is bad, individuals normative Encounter Adverse experiences cause might analyze themselves as being “good” individual to realize they are seen as because they are not committing conscious acts “other” by majority culture of racism and will conclude they are different Immersion/ Individual focuses on their own from “bad” or actively racist white people. For emersion culture, learning more about it and some people, once this analysis has occurred, any reducing or eliminating contact with people of the majority culture information that contradicts the analysis, such as Internalization Individual feels secure with own discussion of unconscious racial biases, can identity and feels able to have cause physical and emotional distress which lim- relationships with people of majority its further discussion and learning. For those who culture are open to what DiAngelo says, however, former Commitment Individual begins to actively work in larger institutional areas such as feelings of discomfort can give way to a deeper politics to address issues of inequity understanding of one’s own internal processes and racism directed at their cultural and a desire to listen and learn in a new way. group

Table 1.2 Helms’ six step white identity development Racial Identity Development model [35] Step Description Another important topic is racial identity devel- Contact White individual has no/limited opment theory, such as the five step model of contact with individuals of minority minority racial identity development by Cross culture and no/limited awareness of racism [34], and the six step model of white racial iden- Disintegration Awareness of racism begins to tity development by Helms [35] (Tables 1.1 and develop 1.2). While space does not allow for a full discus- Reintegration Retreat to a more conscious sion here, racial identity theory proposes that at embrace of white culture as superior some point in the lifespan, individuals become Pseudo- Individual begins to intellectually aware of their cultural identity. For minority indi- independence explore concept of racism in society viduals, this awareness often occurs during the Immersion/ Willingness to confront one’s own emersion personal biases and how one is teen and young adult years with the realization personally benefitting from racism that the individual is being treated differently Autonomy Valuing diversity, actively moving because of racial/ethnic identity, sexual/gender toward a non-racist identity identity, etc. This awareness is often followed by a period of time in which minority individuals education [35]. In both models, some individuals actively reject contact with the majority culture will emerge from these earlier stages to a state of and focus exclusively on relationships with peo- self-awareness that includes openness to authen- ple they see as being like themselves [34]. For tic relationships with people of other cultures and those in the majority culture (white, heterosex- activism. ual, able-bodied, etc.), awareness of cultural In her article Talking about race, learning identity and social disparities often occurs much about racism: The application of racial identity later. For majority individuals this awareness can theory in the classroom [36], Beverly Tatum be followed either by a desire to learn about and describes her experiences teaching psychology associate with people of other cultures or alterna- students about racism and how her knowledge of tively by a retreat back to seeing the majority cul- racial identity theory has helped her to under- ture as “normal” and rejection of further cultural stand moments of impasse or conflict in the 12 A. Emmerich et al. classroom discussions. This article offers impor- Both assumptions and bias can cause clini- tant insights for those engaged in facilitating cians to feel they intuitively know things about cross-cultural dialogue. their patients without asking them. This can be especially true when working with patients from one’s own cultural group such as a white clini- Assumption and Bias cian in the United States assuming that a white patient is literate or has enough financial stabil- An assumption is something that we accept as ity to afford healthy food. In the introduction to true without proof, which our experience has the book Hillbilly Elegy [39], author J.D. Vance not given us reason to doubt. Assumptions may writes “I may be white, but I do not identify with be challenged when we move from our family the WASPs of the Northeast. Instead, I identify or cultural structures into the wider world such with the millions of working-class white as joining the military, going to college or Americans of Scots-Irish descent who have no entering the workplace. A student who has college degree. To these folks, poverty is the been raised in a tight religious community family tradition—their ancestors were day labor- might be surprised, for instance, when first ers in the Southern slave economy, sharecrop- meeting others who do not believe in God. pers after that, coal miners after that, and Likewise, a clinician who has had little contact machinists and millworkers during more recent with Asian people might mistakenly assume times. Americans call them hillbillies, rednecks, that all Asian people speak Chinese and ask a or white trash. I call them neighbors, friends, and Chinese colleague to act as an interpreter for a family.” Vance also says “that is the real story of Korean patient. my life, and that is why I wrote this book. I want While assumptions can arise from lack of people to know what it feels like to nearly give experience, they can also be due to lack of knowl- up on yourself and why you might do it. I want edge. Many in our society, for instance, retain the people to understand what happens in the lives belief that race is due to biological or genetic dif- of the poor and the psychological impact that ferences between people. Many are unfamiliar spiritual and material poverty has on their chil- with results of the Human Genome Study [37] dren” [39]. which showed that genetic differences within groups of people are more significant than genetic differences between groups of people. These and Microaggressions other developments now support the conclusion that race is a social construct rather than due to a Microaggression is a term coined by Chester biological difference [27, 37]. Pierce in 1970 to describe the continuing “stain Bias is commonly defined as a prejudice or of racism” experienced by African-Americans in predisposition in favor of, or against, one person our country [40]. Microaggressions, rooted in or group as compared to another, and can be con- conscious, subconscious or unconscious biases, scious or unconscious [38]. Like assumptions, were defined by Pierce as “subtle, stunning, often biases can create blind spots that might cause a automatic, and nonverbal exchanges which are clinician to miss valuable aspects of the clinical put-downs.” Dr. Pierce suggested that, encounter or to act in ways that patients might In and of itself a microaggression may seem harm- see as unwelcoming. An example of bias in less, but the cumulative burden of a lifetime of healthcare settings might be a heterosexual clini- microaggressions can theoretically contribute to cian who routinely fails to ask open-ended ques- diminished mortality, augmented morbidity, and flattened confidence. [40] tions about sexual practices or a clinician whose feminist attitudes cause her to neglect to ask male Pierce pointed out that because microaggres- primary care patients whether they are feeling sions may be expressed consciously, subcon- threatened in their home setting. sciously or unconsciously, people subjected to 1 Diversity Dialogue 13 them are further hurt by investing expended recognizes that some individuals feel more energies to decipher the perpetrator’s intent. In confident speaking than others, and thus might a 2016 essay titled The Weight [41], author seem more competent just because they are Rachel Kaadzi Ghansah describes this more vocal, can use microaffirmations to expended energy when writing about a journal- acknowledge and center the contributions of ism internship during which an editor told her more timid individuals. she was the first black intern to ever work at a In her video Deconstructing White Privilege, 150-year-old magazine. “So when I was the Vital Conversations on Racism [46], Robin only intern asked by the deputy editor to do DiAngelo gives a powerful example of the impact physical labor and reorganize all of the old of microaggressive behaviors. She describes that copies of the magazine in the freezing, dusty during diversity sessions she asks people of color storeroom, I fretted in private. Was I asked about their interaction with white people with the because of my race or because that was merely question “what would your daily life be like if one of my duties as the intern-at-large. There you could simply give us feedback… and have us was no way to tell” [41]. receive that with grace, reflect, and seek to do Derald Wing Sue expanded on Pierce’s origi- something different.” She states that on one occa- nal work and classified microaggressions into sion a man (of color) in the audience answered, three categories [42, 43]: “it would be revolutionary.” Parekh et al. [47] provide strategies for over- • Microassaults – conscious racist acts such as coming microaggressions in the workplace. The racist graffiti. authors suggest that a first step involves recogni- • Microinsults – derogatory comments related tion and identification of microaggressive behav- to a person’s race or ethnicity. iors. They argue that it is much easier to identify • Microinvalidations – comments that negate the oneself as a victim of microaggressions perpe- reality of a person’s feelings or experiences. trated by others than to recognize oneself as the perpetrator of such behaviors toward others. A While Pierce’s concept of microaggressions greater chance for change however, in the was originally coined to refer to behaviors authors’ opinion, comes from detection of and toward African-Americans by White people reflections upon an individual’s own microag- [40], the concept is applicable to any minority gressive behaviors. Once awareness develops, the group such as women in male dominated envi- next steps involve modification of one’s own ronments or people with disabilities. Rowe behaviors with the hope of understanding the [44, 45], in her role as an ombudsperson at scope of their impact and moving toward elimi- MIT, used the term microinequities to refer to nating them [47]. behaviors toward any non-majority individual It is essential for individuals to accept their such as women or minority individuals work- role and contribution in perpetuating microag- ing in academic institutions or men working in gressive communications in dyadic or group set- jobs traditionally held by women (such as male tings and to courageously engage in a dialogue secretaries and childcare workers). Rowe also that shares observations, reflections, and con- introduced the term microaffirmations as the structive criticism of these relational patterns. reverse phenomenon of microaggressions. She Diversity Dialogue sets the stage for conscious defined these as subtle or small acknowledge- awareness of inner biases and welcomes this ments of a person’s value and accomplishments level of discussion and introspection. It further taking the form of public recognition and com- aims to carefully regulate the pain, discomfort, mendations [45]. The concept of microaffirma- and vulnerability that are provoked by the uncov- tions is an important one for those conducting ering of such microaggressive biases. These any kind of workplace meetings in which there aspects of Diversity Dialogue make it a powerful is a diverse group of workers. A leader who and fertile agent of change. 14 A. Emmerich et al.

The Concept of the “Other” Social processes use dichotomous distinctions between groups of people to enhance power dif- Human beings share the same physiological ferentials and to allow for ongoing use of the needs and mortality. On many levels, though, in “inferior other” for the purpose of identifying our very essence, we each hold on to a distinct and idealizing the dominant “superior” group. outlook on the world that is shaped by myriad Said posed the critical question: “How can one factors, including but not limited to the groups study other cultures and peoples from a libertar- we belong to. A patient-centered approach that ian, or a non-repressive and non-manipulative, includes emphatic listening to patients, respect- perspective?” Dominating groups have to ing their unique worldview, may equilibrate acknowledge their definitions of the “other,” the power differentials. To do so, however, we need minority groups, as their own projections and to to divert away from perceiving people different allow for and listen to the “other” speaking from us as “others.” openly of and for themselves [48]. The concept of the “other” often serves as a One potential consequence of being viewed as vehicle supporting a skewed definition of “nor- “other” is that an individual will internalize the mal.” Differences between groups of people are projection of the majority culture. An example of dichotomized to establish power differentials so this is offered in the book Body of Truth [49]. that members of a dominating group identify Author Harriet Brown quotes a 60-year-old uni- themselves as the antithesis of the “other,” the versity professor talking about how fat shaming subordinated group. impacted her. “I first found out I was a fat person Edward Said, a Palestinian-American literary in kindergarten when people I didn’t know before theoretician, who lived from 1935 to 2003, told me I was a fat person…The tragedy for me is explored the concept of the “other” in his writ- that I judge other large people the way people ings [48]. Said was interested in how people in have judged me. I find myself looking at a large the Western world viewed people from other cul- person and assuming they don’t care enough to tures and how they depicted them in literature. In look right. And that they probably are lazy. And his early career he earned attention for his literary that they’re probably stupid. And I know that analyses of authors such as Joseph Conrad (Heart that’s how people have judged me in the past. It’s of Darkness) and Rudyard Kipling (The Ballad incredible to me that I do that. And I wish I of East and West). In his book Orientalism [48], didn’t.” [49] Said critically analyzed the Western study of Eastern cultures and illuminated the numerous ways that the “Orient” has been defined by Why Dialogue? authors of the West as its contrasting image, idea, and personality: the West in general portrayed as In an article titled What is the Dialogical Method more powerful and “masculine” and the East as of Teaching [50], Shor and Freire discuss a more mysterious and “feminine.” Said asserted method of teaching, initially developed by Freire, that a necessary prerequisite to generating mas- which “rejects narrative lecturing where teacher’s sive and imaginative projections of this kind was talk silences and alienates students.” Freire’s the establishment of a power relationship between model, called Liberatory Education, developed in the West and the East that resulted in the domi- Brazil as an adult literacy movement for nating force feeling empowered to speak of, and oppressed people in the 1950s. Freire calls tradi- for, the “Orient.” He emphasized that the “Orient” tional didactic-learning the “banking model” and is an idea that has a history, a tradition of thoughts, describes it as a process in which the student is an imagery, and vocabulary that have given it reality empty container to be filled with knowledge by and presence in and for the West irrespective of the teacher who holds all the knowledge. He the accuracy with which it reflects true character- argues instead for a model of education in which istics of the East [48]. both the teacher and the student are holders of 1 Diversity Dialogue 15 knowledge to encourage students to speak from underlying judgmental and value-loaded notions personal experience and consequently voice what such as right/wrong or good/bad. Eliciting alter- they, the students, know. Freire says that “dia- nate perspectives may loosen rigid “either/or” logue is a challenge to existing domination… the structures in favor of more nuanced discussions. object to be known is not an exclusive possession Volosinov [53] claims that a word is a two- of one of the subjects doing the knowing…the sided act, a bridge built between people, and sug- object to be known is put on the table between the gests that expression organizes experience by two subjects of knowing” [50]. In Freire’s model, providing its form and specificity of direction. the dialogue is not a spontaneous conversation Volosinov suggests that a realized expression – as but it takes place inside a program and context opposed to a suppressed or inhibited expression – where both the teacher and students are con- is operating on experience in reverse direction, stantly learning and relearning. “If the dialogical beginning to tie inner life together by giving it teacher announces that he or she relearns the more definite and lasting structure. It is therefore material in the class, then the learning process “a matter of not so much of expression accom- itself challenges the unchanging position of the modating itself to our inner world but rather of teacher. That is, liberatory learning is a social our inner world accommodating itself to the activity which by itself remakes authority” [50]. potentialities of our expression, its possible Others have also written about the importance routes and directions” [53]. of dialogue. Yankelovich [51] suggests that while Similarly, White and Epston [54] propose that “ordinary conversation presupposes shared what people know of life they know through frameworks...dialogue makes just the opposite “lived experience” and that in order to make assumption: it assumes that participants have dif- sense of our lives and to express ourselves, expe- ferent frameworks. The purpose of dialogue is to rience must be “storied.” Due to the richness of create communication across the border that sep- lived experience, only a fraction can be “storied” arates them.” Gerzon [52] says that “the power of and expressed at any given time; “those aspects debate is that two polarized voices are free to of lived experience that fall outside of the domi- speak. But the power of dialogue is that these nant story provide a rich and fertile source for the voices can actually be heard.” Gerzon also pro- generation, or re-generation, of alternative sto- poses that “dialogue can only happen to the ries.” Thus, in White and Epston’s view, the text degree that the participants are willing to engage analogy proposes that people’s life stories are in the process. Only then can mistrust evolve into situated in texts within texts and that every telling trust.” He emphasizes the power of re-evaluating or retelling of a story, through its performance, is our assumptions and allowing them to be chal- a new telling that encapsulates and expands upon lenged, all of which are crucial factors in achiev- the previous telling [54]. ing a successful dialogue [52]. Recognition and appreciation of the various forms language can take enhances the power of a Diversity Dialogue: Structure dialogue. In Western culture, dichotomy and and Course binary systems are inherent structures of language and logic. Language, while clearly defining polar- As already mentioned, Diversity Dialogue is a ities of any given human quality, may fail to rep- 3-hour training workshop conducted by a team of resent gradations or “in-between” variations of multidisciplinary members of the Center for the same quality. Some languages may propose a Diversity including psychiatrists, psychologists, host of nouns or adjectives to note or describe a social workers, nurses, and administrators with given phenomenon while other languages may expertise in mental health and cross-cultural totally lack or have only a few terms for the same issues (Table 1.3). Diversity Dialogue has four phenomenon. Concepts and expressions with stages along with distinct Pre- and Post-Dialogue inherent “either/or” structures typically convey activities. 16 A. Emmerich et al.

Table 1.3 Multidimensional comparisons between two diversity education models Diversity dialogue Traditional diversity training Focus on cultural sensitivity/humility; implies ongoing Focus on cultural competence; implies a finite learning with accumulated skills never reaching a final end outcome with a tangible and reachable skill set Uses double-loop learning that reshapes thinking patterns Uses single-loop learning that focuses on skill and triple-loop or transformational learning that increases development [7] self-awareness and alteration of perspectives [7] Focuses on raising unspoken societal issues that are Focuses on more specific objectives: compliance in pertinent to the targeted audience in a professionally the 1960s and 1970s, assimilation in the early 1980s, facilitated holding environment fostering sensitivity in the 1980s and 1990s, and creating a sense of inclusion from 2000 to present time [7] Trainers are active participants who express their Trainers are not active participants and their own perspectives to gain increased awareness of their own biases are not examined limitations and biases Liberatory Model where both the teacher and the student Traditional, didactic, or “banking model” where the are holders of knowledge and both are continuously teacher is the holder of all knowledge and the learning and relearning so that the object to be known is not student is an empty container to be filled with an exclusive possession of one but lies in the space between knowledge [50] the two [50] Challenges existing power differentials; offers an Potentially reinforces existing power differentials opportunity to reduce unspoken tension in power relationships through the social activity of a dialogue [50] Assumes different frameworks with the purpose of creating Presupposes shared framework with less tolerance to communication across the borders that separate people and polarization or diverse perspectives [51, 52] allowing polarized voices to speak and be heard [51, 52]

Pre-Dialogue Needs Assessment We recommend conducting Diversity and Planning Dialogues in a space that can be set up with a U-shaped table for the early part of the Dialogue Each Diversity Dialogue is preceded by a Pre- (so that all participants can easily see and hear Dialogue Needs Assessment Stage. The Center each other) and that also has space for smaller for Diversity Dialogue team appoints two co- “break out” groups later in the Dialogue. leaders for each workshop and six facilitators. Having the support of department and hospital Once a group of 20–25 participants from a leadership is an important aspect of a successful requesting group (hereafter called client) is Dialogue. Tangible measures of leadership sup- identified, Dialogue leaders meet withport have included providing salary/productivity appointed leaders of the client group to explore credit for the hours participants spend at the the reasons for the request and the unique needs Dialogue and department leadership being pres- of the group, along with gauging their expecta- ent at the start of each Dialogue to tell partici- tions for the workshop. A series of three to five pants how much they personally value having a Pre-Dialogue meetings are held to ensure that diverse workforce and to thank participants for expectations are understood on both sides and joining the Dialogue. that logistical issues are being adequately addressed. Finding a 3- to 4-hour block of time during which all participants can be separated Facilitator Training from clinical and administrative duties without interruption, as well as finding adequate space Each Diversity Dialogue includes Pre-Dialogue for the workshop, can be daunting and contrib- training for small group facilitators to acquaint utes to the Pre-Dialogue phase usually lasting them with the issues discussed in this chapter. several months. Facilitators of Diversity Dialogue have later 1 Diversity Dialogue 17 expressed a sense of personal humbleness and ful- After my first time as a facilitator, I realized fillment of long-held wishes to be part of an initia- that my own expectations of baseline sensitivity tive that moves beyond traditional diversity and understanding from the participants had training structures. One such testimony was hampered my performance. Afterward, I was offered by one of the authors of this chapter: increasingly able to see and accept participants’ “Nothing could have prepared me for my journey starting points. Therefore, I was better able to from participant to repeated facilitator. To be hon- support and encourage the process. Each est, as a person of color who has been dealing with Diversity Dialogue helped me move forward and racial and cultural issues since elementary school, open my mind to the next group’s experiences. It I never expected to learn as much as I have. For has been immensely helpful to see the varied background, I am Latino with skin a few shades reactions and deeply personal stories from the lighter than a Hershey bar. I have been called black groups of participants. Their bravery to expose as well as all the related slurs. At other times, peo- their vulnerabilities and share amaze me each ple thought I was Indian or Arabic. When I told my and every time. I am thankful the safe spaces cre- high school calculus teacher I was accepted to an ated by the Diversity Dialogue exists and privi- Ivy league college, he whispered in my ear that it leged to be a part of it.” was really helpful to be a minority. Where are you from? Do you speak English? Are you legal? I am quite familiar with all these Setting the Frame questions as recently as last week. Going into my first Diversity Dialogue, I thought I knew a bit about Each 3-hour Diversity Dialogue starts with sev- the impact of bias and discrimination on others. The eral minutes of discussion about creating a safe training started with a video that focused on an space for the Dialogue and confirmation that overweight white female being thought of as not participation is voluntary. Participants agree to talented, not desirable, and unlikely to succeed. The goals of: group went through all the ways this overweight white female was devalued. I was confused and dis- • Creating a safe space mayed. With all the potential scenarios involving • Engaging honestly gender, country of origin, language ability, or pre- • Taking risks and exploring their beliefs/biases sumption of gender roles, how could we possibly • Keeping an open attitude even start with something as seemingly benign as • Treating the Dialogue as an opportunity for the mistreatment of an overweight white woman learning who notably succeeds and excels at the end of the • Focusing on personal experiences scenario. I thought surely this was too obvious and • Showing a willingness to learn and respect basic an example to elicit much discussion. differences I could not have been more wrong. The partici- • Identifying one to two issues of personal pants were engaged and made many thoughtful interest comments. This overweight woman’s plight spoke to them in a way they could relate to. The somewhat benign nature and less controversial example Stages of the Training of discrimination allowed people to share more freely. I did not come to this realization easily. I had Stage I: “Getting to Know Each Other” to talk it through in detail and share my shock and In Stage I, which typically lasts for an hour, par- confusion with a more experienced member of the ticipants share personal and unique aspects of their Center for Diversity. She supported and guided me heritage or place of upbringing that helped shape through my own biases and discrimination against them into the person they became. Participants people who had spent little to no time or energy receive an email during the week prior to the dealing with issues of race or discrimination. Dialogue asking them to come prepared to give a 18 A. Emmerich et al.

2-minute introduction of themselves that does not Stage III: Building Awareness/Small involve their professional activities or accolades Group Discussions with the prompt “tell a story of where you are In Stage III of Diversity Dialogue participants are from – geographically, spiritually, culturally, eth- divided into small discussion groups, each accom- nically, socio-economically, your home culture or panied by two facilitators. Clinical participants any other cultural theme that contributed to mak- are invited to share a personal story about a clini- ing you the person you are today.” Participants are cal encounter they have experienced that they felt encouraged to bring a small object they feel sym- was impacted by a cultural difference between bolizes an aspect of their cultural history to accom- themselves and the patient; however, they define pany this introduction. Common themes are stories culture. Nonclinical staff are asked to share a per- about countries of origin, religious traditions, sonal story from their school years or training in cross-cultural marriages, lost loved ones, or hob- which they recognized they or others were mak- bies that have led to a community that has become ing a decision based on an assumption or bias or family. Younger members, such as students and in which they witnessed or experienced microag- house staff, often share stories about study abroad gression. A further prompt for the discussion is years when they have felt an awakening of aware- “did anyone do anything to make the situation ness of their own heritage while immersed in the better or worse? Are there things you wish you setting of a different culture. At the end of this first had known then or tools you wish you had?” hour participants often unite or bond in a different way – around the experience of sharing treasured Stage IV: Large Group Reflections and at times nostalgic memories. Everyday power and Intention differentials – such as manager/employee, male/ In Stage IV of Diversity Dialogue, participants female, doctor/nurse, and teacher/student – begin convene as a large group to share highlights of to fade into the background as stories and a sense the themes discussed in their small groups. of togetherness are shared by the group. At the end of the large group reflection, participants are invited to spend a few moments Stage II: Didactic/Cognitive Learning thinking about a personal intention, or next step, In our early Diversity Dialogue workshops, they wish to set for themselves as they leave the Stage II of the Dialogue consisted of a 1-hour Dialogue. Several years after attending a structured didactic scientific or empirical pre- Diversity Dialogue, one clinical director said sentation by a seasoned researcher or clinician “We made some programmatic changes to our on a topic carefully chosen by the Dialogue staff meetings as a result of my going through the leaders to be pertinent and informative to the Diversity training you ran. These were aimed at particular group of participants. Topics included ensuring that all present speak up and that their ways to engage patients from different cultural contributions are valued...I changed my aware- backgrounds in medical or psychiatric inter- ness/behavior as a leader following your session. views, how patients see their healthcare provid- I have seen that others have as well.” ers, and a scientific talk about the neuroanatomy of fear and its association with unconscious biases. Post-Dialogue Evaluation Stage Over time, as Diversity Dialogue facilitators received feedback from participants about how At the end of Diversity Dialogue, participants are much they value the discussion parts of the asked to fill out a survey in which they reflect on Dialogue, the didactic portion was shortened to their experience and point to high and low 20–30 minutes on the themes of assumption, moments in this workshop (see Appendix). bias, and microaggression. A short video Comments offered in these surveys are carefully depicting a cross-cultural vignette is often studied and incorporated in future Dialogues. included. Additionally, an evaluation meeting is held 1 Diversity Dialogue 19 immediately after the Dialogue for facilitators such as microaggression is included in the struc- and the leadership team of the client group; other ture of the dialogue. At our institution this is rein- participants are also invited to stay. First impres- forced with hospital wide programming on topics sions of the dialogue are gathered and logistical related to racism and stigma throughout the year. issues such as timing, the location and size of the The structure of the Dialogue allows for partici- space are also discussed. pants to do most of the talking, another feature Post-Dialogue surveys routinely indicate high cited in studies that look at successful diversity satisfaction among participants, with a majority initiatives. At the end of Diversity Dialogue par- citing the introduction hour and small group dis- ticipants are invited to make a commitment to cussions as being the parts of the Dialogue they themselves for a “next step” that will reinforce an most value. It is not uncommon to hear partici- aspect of the Dialogue they found meaningful. pants say they have worked in the same depart- In 2014, a stated goal of Diversity Dialogue ment for years but never before known anything was “to increase tolerance of and curiosity about personal about each other. Many participants diversity and to ultimately assure the best quality indicate that learning about the concept of micro- of care for all patients” [1]. While this goal aggressions has given them a new perspective on remains, in 2018 the polarization of society that their own behaviors and past experiences. has occurred in the last 2 years gives greater urgency to this work and to the ongoing personal commitment of participants. Tolerance and curi- Closing Comments osity about diversity are no longer enough. Healthcare professionals must actively embrace Americans frequently cite their first amendment learning about these concepts, to understand the right to freedom of speech, particularly when say- varied and unique perspectives of patients from ing something that is hurtful or when speaking all parts of our society who come to them for without listening. Author Brenda Ueland wrote care. They must strive to understand their own “Listening is a magnetic and strange thing, a cre- unique cultural identity and how this impacts ative force. The friends who listen to us are the their interaction with patients. This is particularly ones we move toward. When we are listened to, it true for white clinicians who may not yet feel creates us, makes us unfold and expand” [55]. comfortable with discussion of the history of Diversity Dialogue, designed and piloted by white culture and racism in our society. Or, those the Center for Diversity, Department of Psychiatry who may wrongly feel they need to project a at Massachusetts General Hospital, offers the color-blind attitude which ignores the day-to-day opportunity for healthcare professionals to tran- reality of oppression in patients’ lives and the scend barriers of authority and power, relinquish impact this has on health. the concept of the “other” and listen to each other Lastly, in order to create diverse workplaces in ways that are new and meaningful. It is built where the racial and ethnic demographics of cli- upon the principle of diverting away from dichot- nicians will begin to approximate those of omous or either/or thinking processes and allow- patients, efforts to broaden knowledge about top- ing polarities and diverse perspectives to reside ics related to diversity must be coupled with within a given discussion, provoking feelings of efforts that acknowledge how biases and oppres- discomfort and eliciting change through sharing sion impact equity and inclusion in the workplace stories and opening to new thought patterns. and in the delivery of healthcare. Diversity Diversity Dialogue does these using tools that Dialogue offers a framework in which partici- have been associated in the literature with suc- pants can begin to communicate about these cessful diversity efforts. These include Pre- complex and often uncomfortable topics, despite Dialogue meetings to assess client training needs differences, and to build the relationships needed and eliciting leadership support in tangible ways for working together over the long term to make prior to the dialogue. Cognitive learning on topics meaningful change. 20 A. Emmerich et al.

Appendix: Post-Dialogue Evaluation Survey

Department StaffAdmin

Gender:femalemaletrans other

Q1 Diversity training is relevant to my current practice neither strongly somewhat disagree somewhat strongly disagree disagree or agree agree agree 12 34 5

Q2 Diversity training is relevant to my professional relationships neither strongly somewhat disagree somewhat strongly disagree disagree or agree agree agree 12 34 5

Q3 I feel confident dealing with patients \ people of a background different than myself neither strongly somewhat disagree somewhat strongly disagree disagree or agree agree agree 12 34 5 Q4 Compared to other trainings / lectures, diversity / cultural sensitivity is as important

neither strongly somewhat disagree somewhat strongly disagree disagree or agree agree agree 12 34 5 Q5 I am a culturally confident clinician\person

neither strongly somewhat disagree somewhat strongly disagree disagree or agree agree agree 1 2 3 4 5

Q6 My professional training has adequately trained me to participate in the care of patients of diverse backgrounds neither strongly somewhat disagree somewhat strongly disagree disagree or agree agree agree 1 2 3 4 5 1 Diversity Dialogue 21

Q7 My department\supervisors\ colleagues encourage cultural discussions neither strongly somewhat disagree somewhat strongly disagree disagree or agree agree agree 1 2 3 4 5

Q8 Have you had diversity / cross cultural trainings in the past?

No Not sure Yes

Q9 Why & how is understanding diversity important?

Q10 What did you expect from today's dialogue and were your expectations met?

Q11 Was this diversity dialogue useful and which part of it was most helpful? What stands out for you that you heard\learned today?

Q12 How could we make this dialogue more relevant and helpful to your experience in your Department?

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Nhi-Ha T. Trinh, Trina Chang, and Albert Yeung

Introduction examination so that clinicians can negotiate treatment options in a culturally sensitive manner. Many patients from diverse cultural backgrounds The EIP was developed specifically for mental are unfamiliar with Western biomedical psychiat- health clinicians to use during the diagnostic ric terminology and have high levels of stigma clinical interview. However, the conceptual toward psychiatric illnesses. To enhance commu- framework of the EIP endeavors to approach nication between clinicians and patients and diversity and understanding of mental health in a engage patients in psychiatric treatment, we creative way, outside the usual “medical model.” designed the Engagement Interview Protocol This chapter reviews the growing diversity of the (EIP) to incorporate cultural components into a US population, the importance of understanding standard psychiatric evaluation. The EIP elicits cross-culturally mental health and illness beliefs, patients’ narratives and explores patients’ illness and the development and medical application of beliefs, which are integrated with patients’ infor- the EIP. The concepts behind the EIP itself have a mation on medical and psychiatric history, psy- multidisciplinary origin and can be adapted to chosocial background, and mental status clinical, educational, and research settings to promote an increased appreciation for diversity.

N.-H. T. Trinh (*) The increasing plurality of the US popula- Depression Clinical & Research Program, Massachusetts General Hospital, Boston, MA, USA tion: The United States is becoming increasingly diverse as the growth rate of minority Harvard Medical School, Boston, MA, USA e-mail: [email protected] groups is outpacing that of the White population. Between 2000 and 2010, the Hispanic population T. Chang Depression Clinical & Research Program, in the United States grew by 43%, increasing Massachusetts General Hospital, Boston, MA, USA from 35.3 to 50.5 million, composing 16% of the Harvard Medical School, Boston, MA, USA total population; in 2010, nearly one in six US residents were Hispanic [1, 2]. The Asian popula- Partners Population Health, Partners HealthCare, Boston, MA, USA tion increased from about 4% in 2000 to about 5% in 2010, and the Black population rose from A. Yeung Depression Clinical & Research Program, 12% to 13% of the total population. The American Massachusetts General Hospital, Boston, MA, USA Indian and Alaska Native population maintained Harvard Medical School, Boston, MA, USA its proportion of the total population (0.9%) while growing from 2.5 to 2.9 million. In con- South Cove Community Health Center, Boston, MA, USA trast, while the White population increased from © Springer Nature Switzerland AG 2019 25 R. Parekh, N.-H. T. Trinh (eds.), The Massachusetts General Hospital Textbook on Diversity and Cultural Sensitivity in Mental Health, Current Clinical Psychiatry, https://doi.org/10.1007/978-3-030-20174-6_2 26 N.-H. T. Trinh et al.

211.5 to 223.6 million in the same period, its who have experienced discrimination [9]. In our share of the total population fell from 75% in earlier study of Chinese immigrants in Boston’s 2000 to 72% in 2010. Chinatown, the prevalence of major depressive disorder (MDD) was 19.6% among underserved This increase in the proportion of minority Chinese immigrants in an urban primary care set- populations in the United States is expected to ting, and most of them (96.5%) were untreated continue, leading to a dramatic change in the [10]. In this chapter, we will utilize our experience demographic profile of the United States [3, 4]. of working with Asian immigrants to demonstrate By 2050, the nation’s population will rise to 438 how to develop culturally appropriate interviews as million, from 296 million in 2005, and fully 82% a way to address this public health challenge and to of the growth during this period will be due to bridge these gaps. immigrants arriving from 2005 to 2050 and their descendants; nearly one in five Americans (19%) will be foreign-born in 2050, well above the 2005 Culture and Illness Beliefs level of 12% [5]. According to US Census estimates, by 2044 no race or ethnic group will com- Medical anthropology distinguishes between dis- prise greater than 50% of the nation’s population, ease and illness as two distinct aspects of sick- meaning the United States will soon become a ness. Disease refers to a malfunctioning of “majority-minority” country [6]. biological and/or psychological processes, while illness refers to the psychosocial experience or meaning of perceived disease. Illness is created Minority Mental Health by personal, social, and cultural reactions to dis- in the United States ease [10]. People from different cultures have distinct illness beliefs about the nature of the ill- Despite the trend of growing ethnic diversity, dis- ness, its appropriate treatment, and the kind of parities in mental illness treatment continue to be a relationships within which treatment can take significant public health challenge, as minority place [11]. For example, Marsella [12] suggests patients with mental health illnesses are less likely that the experience and expression of depressive to receive treatment than White patients [7]. For disorders may vary according to the degree of minority patients who do receive mental health Westernization. In European and North American treatment, both the quality of services and patient cultures, depression is a well-accepted psychiat- satisfaction are lower than those of the White popu- ric syndrome characterized by specific affective, lation. The disparities in mental illness treatment cognitive behavioral, and somatic symptoms. By among ethnic groups have been attributed to a contrast, in Nigerian, Chinese, Canadian Eskimo, number of factors. One of the most important Japanese, and Southeast Asian cultures, equiva- causes is lower health literacy and divergent under- lent concepts of depressive disorders are not standings of mental illnesses among minority pop- found [13]. The resulting discrepancy in illness ulations. In addition, the lack of available resources conception between patients and physicians may among minority patients, insufficient culturally explain the lack of motivation of many minority compatible services, and higher stigma of mental patients to receive treatment for depression. illness among minority populations play important roles [8]. Individuals from nonmajority cultural groups often report less satisfaction with healthcare Cross-Cultural Studies of Illness treatment, less shared decision-making with their Beliefs providers, and less overall trust in their providers. These disparities increase with racial, ethnic, and Several studies have investigated illness beliefs linguistic discordance between doctor-patient about depression in specific cultural groups. Our dyads and appear to be further increased in those team used the Explanatory Model Interview 2 The Engagement Interview Protocol (EIP): Improving the Acceptance of Mental Health Treatment… 27

Catalogue (EMIC) [14], a standardized instru- clinicians and patients share similar backgrounds, ment for studying illness beliefs, to investigate it is not uncommon that they diverge in the con- depressed Asian Americans with a low degree of ceptual frameworks they use to understand a par- acculturation and found that many of them were ticular illness [8]. Training that is focused on unaware of, or were unfamiliar with, the concept fostering an attitude of cultural respect and of major depression [15]. This result may explain humility is sorely needed to equip psychiatrists why many Asian Americans focus on physical for this challenge [18]. symptoms and underreport their depressive “Cultural humility” or the “ability to maintain symptoms. It may also explain the clinical chal- an interpersonal stance that is open in relation to lenge of conveying the diagnosis of depression aspects of cultural identity that are most impor- to Asian immigrants, as many of them are unfa- tant to the patient” has been proposed as a key miliar with the illness or might hold strong attitude that predicts success within cross-cul- stigma against being diagnosed with any mental tural clinical encounters [19]. Of note, this move- illness [16]. ment has gained favor in the field of healthcare In another study on the illness beliefs of men- over the previously widely used term “cultural tal illnesses among different ethnic groups [17], competence,” which has been more recently criti- participants were asked, “What do you think cized for implying that there is a finite and static causes depression?” Compared to non-Latino goal to be attained rather than an overall approach Whites, African Americans tended to view men- or attitude that considers the dynamic and multi- tal illness as caused by stress and loss—e.g., the dimensional nature of culture. loss of family friends, stress over money, and Clinicians must be prepared to address a wide stress or worry in general. Asian Americans were range of potential experiences that impact their more likely to believe that family issues, medical patients. The shift from knowledge to skills as illness, and cultural differences caused mental ill- critical; continuing education, by necessity, ness. Latinos tended to attribute mental illness to includes not only the acquisition of knowledge, the loss of family and friends, family issues, and more importantly the development of skills as well moving to a different place. Participants were as attitudes, which may ultimately prove to be also asked, “If you had a mental health problem, more useful. The culturally humble clinician what do you think would help you get better?” expresses respect and a lack of superiority regard- Compared with non-Latino whites, a greater pro- ing the patient’s culture and does not assume com- portion of African Americans said that they petence in terms of working with a patient simply would seek spiritual advice to help them with a based on prior experience with other patients from mental health problem, while Latinos were more similar backgrounds. To address these challenges, likely to endorse a preference for medications; our team developed the “Engagement Interview Asian Americans showed no significant differ- Protocol” to incorporate cultural components into ences in their preferred treatment modalities as the standard psychiatric interview [4] (see compared to non-Latino Whites. “Engagement Interview Protocol” below). These studies demonstrate the impact of culture on illness beliefs, including the attribution of causes of illness and treatment preference. To The Engagement Interview Protocol effectively treat patients from diverse cultural backgrounds, clinicians need to understand, The EIP is a semistructured instrument that inte- appreciate, and effectively negotiate the different grates patients’ illness beliefs into psychiatric viewpoints of the patients they are treating to assessment and evaluation to improve the accep- develop a shared understanding of illness and tance of psychiatric treatment among culturally disease. This negotiation can be particularly chal- diverse populations. By using the information lenging when clinicians come from different cul- obtained from the EIP, clinicians may develop tural backgrounds than their patients. Even when co-constructed illness narratives with patients 28 N.-H. T. Trinh et al. and reframe the Western concept of depression The understanding of the patient’s perspective into more culturally resonant forms [20]. becomes much more important when a clinician sees patients from a culture that is significantly different from his or her own. In such encounters, Development of the EIP the clinician is again like an anthropologist who tries to describe the lives and world of the patient The EIP is based on the format of a standard psy- of a foreign culture; here the clinician focuses on chiatric diagnostic interview, which typically con- learning about the patient’s illness beliefs. To sists of the following sections: History of Present understand patients’ illness beliefs, Kleinman Illness, Past Medical History, Psychosocial proposed listening closely to patients’ narratives History, Mental Status Examination, and and using eight anthropological questions to Psychiatric Diagnoses. To the standard diagnostic summarize the key elements of patients’ illness interview patients’ narratives of their illness, the beliefs to bridge the clinicians’ and patients’ per- EIP adds eight anthropological questions [11] to spectives on the illness [11]. These eight ques- explore patients’ illness beliefs in the “History of tions include: (1) What do you call your problem? Present Illness” section and introduces two new What names does it have? (2) What do you think sections, one on “Culturally Sensitive Disclosure has caused your problem? (3) Why do you think of Diagnosis” and another one on “Customized it started when it did? (4) What does your sick- Approach to Treatment Negotiation.” ness do to you? How does it work? (5) How severe is it? Will it have a short or long course? (6) What do you fear most about your sickness? Incorporating Culture in Psychiatric (7) What are the chief problems the sickness has Assessment caused for you? (8) What kind of treatment do you think you should receive? What are the most The keys to providing culturally sensitive health- important results you hope to receive from the care are developing the ability to understand the treatment? meanings of illness from the patient’s perspec- Most clinicians find these questions very help- tive within the context of his/her cultural back- ful to understand the patients’ perspectives ground, as well as effectively communicating regarding their illness. However, many find it the basis of the medical treatment and its poten- hard to memorize these eight questions in their tial benefits using a framework and language that clinical work. To help clinicians remember these the patient can understand [20]. To bridge differ- eight questions, we created the acronym ent worldviews of people from different cultures “PERCEPTS”: in clinical encounters, clinicians may apply the anthropological approach: collecting and ana- • What is the Problem which bothers you? lyzing both the “insider’s” or “native’s” interpre- • What is its Etiology? tation or “reasons” for his or her customs/beliefs, • What do you think is a good Remedy or as well as examining their (the external research- treatment? er’s) interpretations of the same customs/beliefs • What do you Call the problem? [21]. This approach contrasts with the approach • What are its Effects on you? that is being practiced or taught to clinicians, • How much are you Perturbed (or do you fear) which emphasizes improving the reliability of by the problem? psychiatric diagnosis: Clinicians nowadays are • What do you think Triggered the problem? typically trained to collect data so that patients’ • How Severe is the problem? conditions can be classified as DSM-5 disorders based on the presence or absence of certain In order to describe the influence of culture symptoms [22]; the patient’s perspective can be on patients, on their illness beliefs, and on clini- overlooked or considered as “noise” in the pro- cal encounters, the DSM-5 [22] presents the cessing of clinical data. Outline for Cultural Formulation (OCF) model 2 The Engagement Interview Protocol (EIP): Improving the Acceptance of Mental Health Treatment… 29 and the Cultural Formulation Interview (CFI), cians are better able to use mutually understood which operationalizes the OCF. The current CFI terminology and conceptual frameworks when is a standardized, manualized interview based on they talk with patients about their experiences 16 stem questions and probes [22]. The DSM-5 and treatment options. OCF and CFI uses a semistructured evaluation format for the individualized assessment of cultural factors, including the patient’s identity, ill- The Elements of the Engagement ness experience, and context, as well as of the Interview Protocol clinician-patient relationship. In this model, every patient’s cultural background is described History of Present Illness with Illness in a brief text that includes (a) the patient’s cul- Narratives and Illness Beliefs tural identity, (b) cultural explanations of the individual’s illness, (c) cultural factors related to The “History of Present Illness” section records psychosocial environment and functioning, (d) key clinical information about the onset of ill- cultural elements of the relationship between the ness, precipitants, presenting symptoms, the patient and the clinician, and (e) an overall course of illness, factors that exacerbate or allevi- assessment of diagnosis and care [23, 24]. The ate the symptoms, impairment of social and/or DSM-5 OCF and CFI are a detailed assessment occupational functioning, and responses to treat- that provides a comprehensive description of the ment. Both the patients’ illness narratives and impact of culture on the patient, his/her illness answers to the illness belief questions are beliefs, and the dynamics between the patient explored in this section of the EIP. and the clinician. However, as it requires extensive information gathering, limiting its value as a practical tool for daily clinical work. Patients’ Illness Narratives To address this issue, we developed the EIP, which can be completed within the 1-hour psy- To understand patients’ own illness beliefs, it is chiatric interview, the time allotted by most clini- important to offer patients the opportunity to tell cians and health insurance plans for an initial stories about their illness using their own lan- psychiatric diagnostic assessment. EIP uses a guage and conceptualizations. The narratives fre- streamlined approach focusing on bridging the quently reflect how patients’ culture and social patient’s and the clinician’s understanding of the environment influence the formation, shaping, illness to overcome cultural barriers, with the and presentation of their symptoms. Such stories goal of engaging patients in psychiatric treat- are described by anthropologists as “mini clinical ment. The EIP is based on the format of the stan- ethnographies,” which can be elicited by clini- dard psychiatric assessment but adds to it cultural cians asking open-ended questions about the components based on our clinical experience patients’ concerns and distresses and allowing serving immigrant populations from diverse cul- sufficient time, attention, and interest for patients tural backgrounds: the patient’s narratives of his/ to describe their understanding of their illness [14, her illness experience, Kleinman’s anthropologi- 25]. By empathically listening to the patients’ ill- cal questions on the patient’s illness beliefs, cul- ness narratives, the clinician can learn the patients’ turally sensitive communication of psychiatric perspective and enter into their experiential world. diagnoses, and negotiation of disposition options. The EIP comprises six sections: (1) History of present illness, including the patient’s illness Patients’ Explanatory Models beliefs, (2) Psychosocial history, (3) Mental status examination, (4) DSM-5 diagnoses, (5) Understanding the “cultural explanation of the Culturally sensitive disclosure of diagnosis, and individual’s illness” is essential for achieving an (6) Customized treatment negotiation. Equipped intuitive and empathic understanding of the cul- with this information and understanding, clini- tural meanings of symptoms to patients, for 30 N.-H. T. Trinh et al. shaping how illness will be disclosed to the ship with the patient, as well as whether the patients, and for negotiating treatment patient has a strong family support network; (7) approaches. past and current job history; and (8) the patient’s To elicit the patient’s cultural explanation of his/ interpretations of social support networks, stress- her illness, the EIP has included the “PERCEPTS” ors, and levels of functioning and disability. questions based on Kleinman’s eight anthropologi- If the patient is a recent immigrant, it is usu- cal questions [11]. This data enables clinicians to ally highly informative to ask about his/her co-construct interpretations of the illness with their adjustment to the host country. Most immigrants patients, which is usually done by bridging DSM are enthusiastic to talk about their views of the diagnostic categories with the individual’s con- United States, whether or not they have adapted cepts. Such a process is used below, both for com- well to the new environment and their jobs, municating about patients’ illness and for whether they are satisfied with their lives, and discussing treatment options in a culturally sensi- whether they face obstacles in seeking help/care. tive way.

Mental Status Examination Psychosocial History Please refer to Kaplan and Sadock for a discus- This part of the psychiatric interview elicits sion of general components of a mental status information on the patient’s personality, cultural examination, and to Hays for a discussion of affiliation, self-identity, childhood experience, complexities regarding mental status examina- education, job history, aspirations, and major life tions for minority patients [26, 27]. goals. It corresponds to two core elements of the DSM-5 Cultural Formulation model: the “cultural identity of the individual” and the “psycho- DSM-5 Diagnoses social stressors and cultural features of vulnerability and resilience.” Psychiatric diagnoses are presented using the dis- To understand the psychosocial history of the orders in DSM-5. Despite the fact that some patient, the EIP uses direct questioning to elicit patients’ explanatory models may not fit DSM-5 information on patients’ developmental, immi- diagnostic categories, using this system of diag- gration, and work history, current social environ- noses facilitates communication among mental ment, and perceived stressors. These items health professionals and insurance payers in the include (1) country of origin, childhood develop- US healthcare system. mental experience, and school and social experiences; (2) level of education and the schools attended; (3) immigration history (when applica- Culturally Sensitive Disclosure ble), including the reason for immigrating to the of Psychiatric Diagnoses host country and how it took place, the duration of stay, current immigration status, cultural refer- Disclosure of the psychiatric diagnosis to patients ence group, language abilities, degree of involve- from diverse cultural backgrounds with traditional ment with both the culture of origin and the host illness beliefs poses a great challenge clinically, culture, and the extent to which the goals of since these patients tend to be less familiar with immigration have been achieved; (4) marital sta- the concept of mental disorders, endorse stigma tus, relationship with spouse, and current marital toward psychiatric problems and services, and issues if present; (5) spiritual/religious beliefs interpret symptoms according to their cultural- and the role of religion in the patient’s life; (6) specific beliefs [14]. The EIP approach to the cul- family members, their locations, their socioeco- turally sensitive disclosure of psychiatric diagnoses nomic status and occupation, and their relation- is informed by anthropological literature and the 2 The Engagement Interview Protocol (EIP): Improving the Acceptance of Mental Health Treatment… 31 experience of our team. It includes the following antidepressant would act to relieve symptoms components: (1) eliciting patient’s illness beliefs such as sadness, insomnia, and fatigue by as described in the “History of Present Illness” restoring balance to the system, by tonifying ( Section above, (2) accepting multiple explanatory 补脑 bu. nao), or by strengthening the energy models, (3) reframing Western psychiatric con- of the brain. Similarly, relating the concepts of cepts, (4) clarifying the meanings of diagnostic “balance” and “imbalance” to the patient’s labels, (5) using flexible terminology, and (6) dis- interpersonal life and physical condition closing diagnoses and treatment approaches in would be another way to tailor Western psy- stages. Below we give an example of using this chiatric concepts to fit within a contextual, framework with the immigrant Chinese American family-centered, physical/somatic framework population when the clinician diagnoses the for Chinese patients. None of these explana- patient with major depressive disorder. tions runs contrary to modern psychiatric thinking; rather, these reframings make the 1. Eliciting the patient’s illness beliefs: explanations more accessible and familiar to As described above, the EIP elicits patients’ the patients. beliefs about their interpretation of their ill- 4. Clarifying the meanings of diagnostic labels: ness: what caused and triggered it, how it Many non-Western immigrants tend to associ- affects their lives, and what they consider ate all psychiatric terms with insanity. It is good remedies for the illness. important to explain to them what a specific 2. Accepting multiple explanatory models: psychiatric diagnosis means. Using again the When patients’ explanations of their illness example of communicating the diagnosis of differ from the ones offered or contended by major depressive disorder, one useful Western medicine and psychiatry, clinicians approach is to say, “You have reported having are encouraged to take an accepting stance. symptoms like sadness, sleep disturbance, Instead of asserting the Western conceptions loss of interest, blaming yourself, loss of of the illness, clinicians could use patients’ appetite and being irritable. In Western medi- explanations as the basis for discussing treat- cine, these symptoms are called depression.” ment rationale and expected outcomes, since 5. Flexible use of terminology: such explanations are meaningful for them. In our experience working with Chinese 3. Reframing Western psychiatric concepts: immigrants, the choice of Chinese transla- If patients are familiar and comfortable with tions of psychiatric disorders is very impor- conventional psychiatric diagnoses, reframing tant to avoid stigmatized connotations. To may not be necessary. Very commonly, how- avoid being too technical, Western clinicians ever, patients from other cultures may not often use the more colloquial term “depres- share those conceptualizations of psychiatric sion” rather than “major depressive disorder” illness. In our previous study of depressed when working with English-speaking Chinese immigrants, when the patients were patients. With Chinese-speaking patients, asked for a reason for their illness, 55% there are several choices of translation. responded, “I don’t know.” The rest of the Strictly translated into Chinese, the term patients attributed their symptoms to medical “major depressive disorder” becomes zhong causes, interpersonal issues, or magical forces xing you yu zheng (重型忧鬰症), which lit- [28]. Thus, with Chinese immigrants, the erally means “severe depressive disorder.” In monoamine hypothesis of depression might practice, clinicians or their Chinese interpret- be framed as an imbalance of chemicals in the ers often use the terms you yu zheng (抑鬱 brain due to stress. This explanation would be 症), or yi yu zheng (忧鬰症), which would be readily understood because it overlaps with translated as “depressive disorder.” We sug- Yin and Yang theory in traditional Chinese gest using an even more general term such as medicine. According to this framework, an you yu (忧鬰), or “depression,” which, like 32 N.-H. T. Trinh et al.

its English equivalent, can refer to both a nor- treatment negotiation. Treatment negotiation mal variation of mood as well as a pathologi- empowers the patient and shows that the clinician cal state. This term would be more acceptable respects the patient’s point of view; in a practical to many Chinese immigrants who are less sense, it may facilitate engaging patient into treat- acculturated and is analogous to the use of the ment. Clinicians may start by providing the ratio- more colloquial term “depression” rather nale for treatments, usually aimed at alleviating than “major depressive disorder” with patents’ suffering and reducing the functional English-speaking patients in the West. impairment caused by the medical/psychiatric con- Going even further, it might be acceptable to ditions that prompted the visit. Clinicians should avoid mental health jargon all together and then discuss available treatment options, provide use simple descriptive language. One example the rationale for and pros and cons of each treat- might be to inform a patient that “all your per- ment, and inform the patient of possible side effects sonal problems have taken a toll on you, and [13]. If the patient is reluctant to initiate pharmaco- now you are feeling sad and tired which also logical or psychological treatment, then reassurance bring along other symptoms that you are and clarification of underlying fears or worries experiencing.” While we propose using flexi- about treatment are frequently helpful. Since many ble terminology, at least in the initial visits patients come to the clinic with specific illness with patients when they are unfamiliar with beliefs, needs, and requests in mind, clinicians need technical terms, we would like to emphasize to be open-minded and flexible to allow open com- that clinicians should still be truthful. We munication between patient and clinician [14]. encourage clinicians to use plain language and Negotiation between patients and practitioners over a conceptual common ground in co-construct- salient conflicts almost always contributes to more ing explanations for the illness, which may empathic and ethical treatment. The questions from lead to a more successful negotiation of treat- the History of Present Illness section, “What kind of ment (see below). We do not support using treatment do you think you should receive?” and deceptive terms with patients, since this would “What are the most important results you hope to be ethically unacceptable and could jeopar- receive from the treatment?,” provide the back- dize trust between clinicians and patients. ground information for treatment negotiation. 6. Disclosing diagnoses and treatment Part of treatment negotiation may involve approaches in stages: exploring the patients’ understanding of as well as The technical term for the psychiatric diagno- preference for medication treatment, counseling, sis can and should be offered to the patient, as and other treatment measures, and to clarify mis- it is a legal requirement for full disclosure. On conceptions or worries (e.g., “can counselors the other hand, such disclosure should happen keep things confidential”) that might exist. For after the correct concepts and nature of the ill- example, many Chinese immigrants are not famil- ness have been communicated to minimize iar with psychotherapy treatment, what it entails stigma and surprise. At that point, the diag- or how it could be helpful to them. On the other nostic term can be presented in a way that is hand, a fraction of Chinese immigrant patients culturally resonant. who are emotionally overwhelmed actively seek “talk therapy” for their need for catharsis, emotional support, and guidance. Many of them have A Customized Approach to Treatment heard of and like the term counseling “心理辅導” Negotiation (xin li fu dao), which connotes psychological guidance or coaching. Other patients may have a After exploring the patient’s illness beliefs about the preference against medication treatment. For illness and taking the necessary steps to disclose the example, many Chinese immigrants either con- patient’s diagnosis, the clinician enters into the sider psychotropics to be treatment for the insane 2 The Engagement Interview Protocol (EIP): Improving the Acceptance of Mental Health Treatment… 33 or question the usefulness of medications for worries about tension with her teenage son, who solving their psychosocial problems, the focus of had been having difficulties at school. their worries. We find that the concept of imbalance of neurotransmitters in the brain triggered by stress and/or depression is helpful for framing this Patient’s Explanatory Model of Her discussion and is well received by many Chinese Illness Experience or “PERCEPTS” Americans, probably because it is similar to the concept of imbalances of yin and yang, a corner- 1. Problem?: “heartburn” stone of Chinese philosophy. 2. Etiology?: “not sure” The negotiation may end up with a compro- 3. Remedy?: “If tension with my son is resolved, mise, which could be closer either to the patient’s I will be fine” or the doctor’s position. If for technical or ethical 4. Call the problem?: “heartburn, possibly reasons the physician is uncomfortable with the depression” compromise, referral should be made to another 5. Effects on you?: “Heartburn, sadness, tired” practitioner. It is important to maintain honesty, to 6. Perturbed (or fear) the most: “my son is not accept criticism, and to be open to discussing one’s doing well” uncertainty and the limits of one’s understanding. 7. Trigger: “sister passed away recently” 8. Severity: “pretty bad”

Case Vignette Culturally Sensitive Disclosure In the following section, we use a case vignette of of Diagnosis a Chinese patient who fit the DSM-5 criteria for major depressive disorder as an example of how The patient did not label her problems as depres- to adopt a patient’s illness beliefs in disclosing sion, and she focused on her physical symp- the patient’s illness and in negotiating treatment. toms. Yet when she was asked about specific Identifiers have been changed and histories depression symptoms, she acknowledged hav- merged to protect patient confidentiality. ing many of them. She believed that her symptoms were due to worries about her son. With some guidance, she was able to see that tension Case Vignette: A Patient with a Chief with her son had been distressing to her, and that Complaint of Heartburn the death of her sister actually moved her off- balance. We acknowledged the discomforts The patient was a divorced Chinese female in her from her heartburn but reassured her that her forties who immigrated to the United States primary care physician had already performed about 5 years ago. She worked as a waitress in a the necessary tests and that the risks of having restaurant and reported that her job and her rela- problems in her heart or stomach was low. We tionships at work were fine. She started to experi- pointed out that when people were under a lot of ence heartburn 2 months ago. Her primary care pressure, acid from the stomach could rise up physician saw her for a checkup and referred her and cause heartburn sensations. We asked her if for a consultation. When asked specifically about she had heard of depression (yi yu zheng) and depressive and neurovegetative symptoms, she whether she might be suffering from depression. reported having depressed mood, insomnia, loss She replied that she was not familiar with the of interest, guilty feelings, and irritability. Upon term and she was not sure if she had the illness. further investigation, she reported that her sister We informed her that while it might be too early recently passed away due to an illness about to conclude, there might be a possibility that she 2 months ago. She also expressed significant actually had depression. 34 N.-H. T. Trinh et al.

Customized Approach to Treatment Conclusion Negotiation Culture plays an important role in influencing the In negotiating treatment, she was informed that formation and presentation of psychiatric prob- there are medications available to reduce her lems and patients’ illness beliefs. The EIP is a worries as well as her other related symptoms, practical tool that incorporates cultural compo- including heartburn, sadness, insomnia, loss of nents into the usual psychiatric assessment for- interest, and irritability. We informed her that mat and is designed to fit into a standard 1-hour tension between her and her son could be less- initial psychiatric evaluation. The EIP explores ened if her mood improved and she had more patients’ cultural explanations of illness by elicit- energy and resources to educate him. Possible ing patients’ narrative descriptions and used side effects of this class of medications were structured illness-belief questions. The EIP also discussed. The patient agreed to try the medica- uses standardized items to elicit patients’ psycho- tions and see if they could help her. She was social history and generates information on prescribed mirtazepine at the end of the patients’ cultural identity, psychosocial environ- interview. ment, and levels of functioning. By providing a more complete understanding of the patients’ cultural background, the EIP may Incorporating the EIP in Clinical improve communication between practitioners Interventions and their patients and enhance culturally sensitive disclosure of psychiatric diagnosis and In our initial field testing with depressed Chinese engagement of patient into psychiatric treatment. immigrants, the EIP model was found to be a Initial trials using the EIP in Chinese American practical tool that can be completed within the and Latino American underserved populations allotted 1-hour time frame and was highly effec- with depressive symptoms have been promising. tive in facilitating the enrollment of patients in Future applications of the EIP may be broadened treatment for depression [27, 28]. The EIP has to include a variety of medical, research, and also been more recently incorporated in a cultur- educational settings and may enable a variety of ally focused psychiatric (CFP) consultation ser- professionals to more effectively communicate vice for Latino Americans [29, 30]. In a with the populations they serve. randomized, clinical trial of 118 Latino Americans with depressive symptoms, 85% of participants responded positively to all questions The Engagement Interview Protocol of the satisfaction scale. In in-depth interviews, (EIP) the vast majority of participants reported the program met expectations, all stated providers were I. History of Illness culturally sensitive, and most stated recommen- A. History of present illness dations were culturally sensitive [30]. In addi- Patient’s narratives on personal illness tion, depression symptom reduction was greater experience among CFP intervention participants (mean ± SD Patient’s cultural explanatory of his/her change in QIDS-SR score = 3.46 ± 5.48) than illness: (“PERCEPTS”) those in usual care (change = 0.09 ± 4.43) [31]. 1. What is the Problem which bothers These results suggest that Latino Americans you? experiencing depressive symptoms found this 2. What is its Etiology? treatment negotiation approach of the EIP accept- 3. What do you think is a good Remedy able, and that this underserved population may or treatment? benefit from a short-term CFP consultation using 4. What do you Call the problem? the EIP [32, 33]. 5. What is its Effects on you? 2 The Engagement Interview Protocol (EIP): Improving the Acceptance of Mental Health Treatment… 35

6. How much are you Perturbed (or do G. Discuss the pros and cons of treatment you fear) by the problem? options 7. What do you think Triggered the H. Negotiate and finalize treatment plan problem? I. Discuss potential side effects from treat- 8. How Severe is the problem? ment and possible remedies B. Past psychiatric/medical history C. Family history II. Psychosocial History References A. Past psychiatric/medical history B. Family History 1. US Census 2000. U.S. Census Bureau, New York. Department of Labor. https://www.census.gov/mp/ C. Immigration history www/cat/decennial_census_2000/mapping_cen- The date, purpose, and process of immi- sus_2000_the_geography_of_us_diversity.html. gration; adjustment in the host country 2. US Census 2010. U.S. Census Bureau, New York. D. Marital history Department of Labor. www.census.gov/2010census/ news/releases/operations/cb11-cn125.html. E. Spiritual/religious beliefs 3. Bau I. 2011. http://ignatiusbau.com/2011/03/25/u-s- F. Family support network: census-changes-in-u-s-racial-and-ethnic-populations- With whom do you live? from-2000-to-2010/. How is your relationship with your 4. Morrison J, Munoz RA. Boarding time: a psychiatric candidate’s guide to Part II of the American Board spouse, parents, siblings, children, etc.? of Psychiatry and Neurology Examination. 4th ed. G. Past and current job Washington, DC: American Psychiatric Press; 2009. H. Social supports 5. Pew Center. 2008. http://www.pewhispanic. I. Stressors org/2008/02/11/us-population-projections- 2005-2050/. J. Levels of functioning 6. Colby SL, Ortman JM. Projections of the size and III. Mental status examination composition of the U.S. population: 2014 to 2060. US Appearance: Census Bur. 2015 Mar; 13. Attitude: 7. Surgeon General. U.S. Department of Health and Human Services. Mental health: a report of the Behavior: Surgeon General—Executive Summary. Rockville, Speech: MD: U.S. Department of Health and Human Services, Motor: Substance Abuse and Mental Health Services Mood: Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Affect: Ment Health; 1999. Thought process: 8. Yeung A, Kam R. Culturally sensitive approach to Thought content: discussing psychiatric diagnoses with less accultur- Perception: ated Chinese immigrants: reconciling the gap using MDD diagnosis delivery in less-acculturated Chinese Cognition and intellectual resources: patients. Transcult Psychiatry. 2008;45(4):531–52. Insight/judgment: 9. Institute of Medicine (US) Committee on IV. DSM-5 Psychiatric diagnoses Understanding and Eliminating Racial and Ethnic V. Culturally sensitive disclosure of diagnosis Disparities in Health Care. Unequal Treatment: Confronting Racial and Ethnic Disparities in A. Elicit the patient’s illness beliefs Health Care [Internet]. Smedley BD, Stith AY, B. Accept multiple explanatory models Nelson AR, editors. Washington (DC): National C. Clarify the meanings of diagnostic labels Academies Press (US); 2003 [cited 2018 Mar 26]. D. Sensitive and flexible use of Available from: http://www.ncbi.nlm.nih.gov/ books/NBK220358/. terminology 10. Weiss M. Cultural models of diarrhea illness: E. Disclose in stages conceptual framework and review. Soc Sci Med. VI. A customized approach to treatment 1988;27(1):5–16. negotiation 11. Kleinman A. Patients and healers in the context of culture: an exploration of the borderline between anthro- F. Explore the patient’s understanding and pology, medicine, and psychiatry. London: University preferences for treatment of California Press; 1980. 36 N.-H. T. Trinh et al.

12. Marsella AJ. Depression experience and disor- 24. Lewis-Fernandez R, Naelys D. The cultural for- der across cultures. In: Triandis H, Draguns J, mulation: a method for assessing cultural fac- editors. Handbook of cross-cultural psychology, tors affecting the clinical encounter. Psychiatry Q. Psychopathology, vol. 6. Rockleigh: Allyn & Bacon; 2002;73(4):271–95. 1980. 25. Kleinman A. The illness narrative: suffering, healing, 13. Marsella AJ, Sartorius N, Jablensky A, Fenton and the human condition. New York: Basic Books; FR. Cross-cultural studies of depressive disorders: an 1988. overview. In: Kleinman A, Good B, editors. Culture 26. Hays P. Addressing cultural complexities in practice: and depression. Berkeley: University of California assessment, diagnosis, and therapy. 3rd ed. Washington, Press; 1985. p. 299–324. DC: American Psychological Association; 2016. 14. Weiss M. Explanatory Model Interview Catalogue 27. Kaplan BJ, Sadock VA. Comprehensive textbook of (EMIC): framework for comparative study of illness. psychiatry. 9th ed. Philadelphia: Lippincott Williams Transcult Psychiatry. 1997;34:235–63. & Wilkins; 2003. 15. Yeung A, Kung WW. How culture impacts on the 28. Lazare A, Eisenthal S, Wasserman L. The cus- treatment of mental illnesses among Asian Americans. tomer approach to patienthood: attending to patient Psychiatr News. 2004;21(1):34–6. requests in a walk-in clinic. Arch Gen Psychiatry. 16. Yeung A, Kam R. Illness beliefs of depressed Asian 1975;32:553–8. Americans in primary care. In: Georgiopoulos AM, 29. Yeung A, Yu SC, Fung F, Vorono S, Fava Rosenbaum JF, editors. Perspectives in cross-cultural M. Recognizing and engaging depressed Chinese psychiatry. Philadelphia, PA: Lippincott Williams & Americans in treatment in a primary care setting. Int J Wilkins; 2004. p. 21–36. Geriatr Psychiatry. 2006;21:819–23. 17. Jimenez DE, Bartels SJ, Cardenas V, Dhaliwal SS, 30. Yeung A, Shyu I, Fisher L, Wu S, Yang H, Fava Alegría M. Cultural beliefs and mental health treat- M. Culturally sensitive collaborative treatment ment preferences of ethnically diverse older adult (CSCT) for depressed Chinese Americans in primary consumers in primary care. Am J Geriatr Psychiatry. care. Am J Public Health. 2010;100(12):2397–402. 2012;20(6):533–42. 31. Trinh N, Bedoya C, Chang T, Flaherty K, Fava M, 18. Lokko HN, Chen JA, Parekh RI, Stern TA. Racial and Yeung A. A study of a culturally focused psychi- ethnic diversity in the US psychiatric workforce: a atric consultation service for Asian American and perspective and recommendations. Acad Psychiatry. Latino American primary care patients with depres- 2016;40(6):898–904. sion. BMC Psychiatry. 2011;11:166. https://doi. 19. Hook JN, Davis D, Owen J, DeBlaere C. Cultural org/10.1186/1471-244X-11-166. humility: engaging diverse identities in therapy. 32. Trinh NH, Hagan PN, Flaherty K, Traeger LN, Washington, DC: APA Press; 2017. Inamori A, Brill CD, Hails K, Chang TE, Bedoya CA, 20. Yeung A, Trinh NH, Chang TE, Fava M. The Fava M, Yeung A. Evaluating patient acceptability of engagement interview protocol (EIP): improving a culturally focused psychiatric consultation interven- the acceptance of mental health treatment among tion for Latino Americans with depression. J Immigr Chinese immigrants. Int J Cult Mental Health. Minor Health. 2014;16(6):1271–7. 2011;4(2):2011,91–105. 33. Bedoya CA, Traeger L, Trinh NT, Chang T, Brill 21. Headland TN, Pike KL, Harris M, editors. Emics and C, Hails K, Hagan P, Flaherty K, Yeung A. Impact etics: the insider/outsiders debate, Frontiers of anthro- of a culturally-focused psychiatric consultation on pology series, vol. 7. Newbury Park: Sage; 1990. depressive symptoms among Latinos in primary care. 22. APA. Diagnostic and statistical manual of mental dis- Psychiatr Serv. 2014;65(10):1256–62. order. 5th ed. Washington, DC: American Psychiatric Association; 2013. 23. Lewis-Fernandez R. Cultural formulation of psychiatric diagnosis. Cult Med Psychiatry. 1996;20:133–44. Cultural and Diversity Issues in Mediation and Negotiation 3

David Alan Hoffman and Katherine Triantafillou

This chapter is excerpted and adapted from a ples counseling, family therapy, parent–child chapter by the same authors in David Hoffman counseling, or simply the setting of boundaries et al., Mediation: A Practice Guide for Mediators, and ground rules in individual psychotherapy, Lawyers and Other Professionals (Massachusetts mental health practice has much in common Continuing Legal Education 2013). A series of with the work that mediators do. In this chapter, asterisks marks the location of material deleted we offer the perspectives of two practicing from the original version. mediators on a subject that is critical to the The terms “mediation” and “negotiation” are work of both mediators and mental health used interchangeably in this article, although professionals—namely, cultural and diversity they are distinct concepts. Mediation is a process issues. whereby a neutral facilitator helps two or more Mediators routinely encounter racial, people in a dispute resolve that dispute through cultural, and other forms of diversity in their dialogue. Negotiation is essentially the dialogue work, and therefore no curriculum of mediation that two or more people have regarding an issue training would be complete without in which they wish to reach an understanding or consideration of the challenges (and agreement. opportunities) that accompany such diversity. In the Massachusetts Uniform Rules on Dispute Resolution, cultural diversity is listed as one of Introduction the “critical issues” in the training curriculum required for court-approved mediation Mental health professionals often engage in programs [1]. professional work that resembles mediation Mediation is sometimes described as “making and negotiation. Whether in the form of cou- a safe place for a difficult conversation.” Mental health professionals are often engaged in that D. A. Hoffman (*) same process, and among the things that make Boston Law Collaborative, LLC, Boston, MA, USA conversations difficult are the differences Harvard Law School, Cambridge, MA, USA described in this chapter. Although we cannot treat this subject Attorney and Mediator, Cambridge, MA, USA e-mail: [email protected] exhaustively in one chapter, we can offer perspectives—both our own and those of experts K. Triantafillou Attorney and Mediator, Cambridge, MA, USA in the field—as an introduction to some of the e-mail: [email protected] diversity issues that arise in mediation.

© Springer Nature Switzerland AG 2019 37 R. Parekh, N.-H. T. Trinh (eds.), The Massachusetts General Hospital Textbook on Diversity and Cultural Sensitivity in Mental Health, Current Clinical Psychiatry, https://doi.org/10.1007/978-3-030-20174-6_3 38 D. A. Hoffman and K. Triantafillou

The Seeds of Difference One of the primary roles of the mediator (and mental health professional) is to be impartial The word “barbarian” in ancient Greece was used regardless of the parties’ circumstances and dif- to delineate between those who were born Greek ferences and to bring an open mind and heart to and those who were not; those who spoke Greek the process. And yet mediators often find them- properly and those who did not; and later, those selves feeling more sympathetic to one party than who were considered to be civilized (the Greeks) another, even while they exhibit behavior that the and those who were not (the Persians). parties view as impartial. Moreover, experience Throughout history we encounter countless quickly teaches mediators that the parties do not examples of how humans have differentiated meet on a level playing field—one in which the themselves from each other, whether it is based disputants are fairly equal in power and informa- on country of origin, race, religion, tribe, or lan- tion or can be made equal by a process that shares guage, to name just a few of the familiar lines of information and incorporates or acknowledges demarcation. difference in ways that promote good communi- Had anyone told the ancient Greeks that the cation. All too often, differences create advan- use of the word “barbarian” was discriminatory tages and disadvantages at the bargaining or prejudicial toward non-Greeks, they probably table—some of them reflecting a differential in would have snorted in disdain. In those times, the parties’ resources, and some of them internal- being able to identify who was an outsider and ized attitudes of superiority on the one hand or who was not often became a matter of life and fear and disempowerment on the other. In addi- death. The homogenous character of the modern tion, people come to the mediation table with Greek state, like many European states, is begin- vastly different life experiences—some of them ning to change. However, different ethnicities in the result of mistreatment based on race, gender, Greece are oftentimes greeted today in much the or other characteristics. Or, the parties may have same way as they were in Plato’s time, as Greece positive feelings about their differences—for struggles to integrate refugees from Pakistan, example, a person’s ethnic, regional, or racial Afghanistan, Bangladesh, and Sudan. heritage may be a source of pride and may even While Buddhists teach that we are all from the be celebrated by society as a whole. same cosmic soup and therefore share a common Even if the disputants are two white middle- humanity, most of us have ingrained reactions to aged educated individuals who live in the same people who are different from us. (See discussion city, work for the same corporation, and ostensi- below regarding “implicit bias.”) Every nation or bly speak the same language, sometimes they are culture has a “them”—the dreaded “other” that not speaking the same language, especially when represents a real or imagined threat to its safety. one is a male and one is a female complaining And every individual makes thousands of split- about sexual harassment. Or, if one disputant second judgments about his or her environment comes from a family that reveres holidays and and the people who inhabit that environment, has numerous memories of happy gatherings engaging in a type of cultural shorthand that with smiling faces and the other comes from a makes negotiating daily life easier. For example, family whose dysfunction was especially acute when we encounter someone who is fashionably during the holidays with excessive drinking or attired and driving a Maserati, or someone who violent episodes and broken furniture, will they looks dirty and disheveled, carrying an empty approach the task of constructing a parenting cup, and asking for handouts, we make unavoid- schedule for the holidays in the same way? If the ably hasty judgments—at what point do those mediator’s family holidays were centered on judgments veer into the territory we call “preju- somber religious activities, how will that affect dice” or “bias?” At what point do those judg- the mediation of that schedule? What if the medi- ments inhibit us from experiencing the people in ator has an incest history, the bulk of which our world with an open mind and an open heart? occurred during family holidays? 3 Cultural and Diversity Issues in Mediation and Negotiation 39

Given the vast differences that make up who Professor Deborah Kolb and researcher Gloria we are as human beings, is it possible to truly Coolidge explore these gender differences by manage differences sufficiently to ensure the pro- focusing on how men and women tend to negoti- cess is fair to the participants? Can we empower ate differently [4]: participants sufficiently that their past experi- Women speak differently. Their assertions are ences are not a barrier to meaningful mediation? qualified through the use of tag questions and mod- There are no easy answers to any of these ifiers … the female pattern of communication questions, no boilerplate checklists that will pro- involves deference, relational thinking in argument, and indirection. The male pattern typically vide the correct path through the maze that we involves linear or legalistic argument, depersonali- call diversity and inclusion. The purpose of this zation, and a more directional style. While women chapter is to point mediators and mental health speak with many qualifiers to show flexibility and professionals in the right direction and to suggest an opportunity for discussion, men use confident, self-enhancing terms. the types of questions we might ask ourselves and the parties about our differences. Anticipating that assertiveness may lead away from connection, women tend to emphasize the needs of the other person so as to allow that other person to feel powerful. Her behavior may thus Mediation and the Problem of Bias appear to be passive, inactive, or depressed. Professor Linda Babcock performed experiments One of the persistent criticisms of mediation is with men and women as advocates for themselves that bias is less controllable in informal forums, and others in salary negotiations and found that and thus the preferred method of dispute resolu- women tend to be less forceful advocates for tion in cases where such bias is a factor is litiga- themselves but are more forceful when advocat- tion, where there are strict rules of procedure, a ing for others. For men, the pattern was the oppo- public forum, and a judge to oversee the process site—they were more assertive than women when [2]. This is an argument frequently put forward advocating for themselves and somewhat less so by gender specialists who caution that the use of when advocating for others [5]. mediation, especially mandatory mediation, is This is one of the primary reasons why counterproductive, even harmful, given the power domestic violence experts are adamantly opposed imbalances that often exist between men and to the use of mediation. Aside from the physical women in our society. The late Trina Grillo, a law risk of continued close contact, in order for a professor known for her gender-based critique of battered spouse to leave the batterer, she must mediation, makes the argument forcefully: overcome societal and internal expectations that Mandatory mediation can be destructive to many she stay to keep the family intact. Engaging in women and some men because it requires them to mediation during that crucial period when an speak in a setting they have not chosen and often imposes a rigid orthodoxy as to how they should abuse victim has finally broken through her speak, make decisions, and be. This orthodoxy is silence and publicly acknowledged being battered imposed through subtle and not-so-subtle mes- can easily retard the victim’s nascent sense of sages about appropriate conduct and about what independence and selfhood. In addition, the may be said in mediation. It is an orthodoxy that often excludes the possibility of the parties speak- informality of mediation allows the batterer the ing with their authentic voices. Moreover, people opportunity to continue the psychological vary greatly in the extent to which their sense of manipulation inherent in the relationship, self is “relational”—that is, defined in terms of frequently impressing the neutral party with his connection to others. If two parties are forced to engage with one another, and one has a more rela- normalcy, charm, or erudition. It can also cause tional sense of self than the other, that party may the victim to distrust her own instincts for survival. feel compelled to maintain her connection with the This is especially true when mediation is focused other, even to her own detriment. For this reason, on the present and participants are admonished to the party with the more relational sense of self will be at a disadvantage in a mediated negotiation [3]. ignore past conduct or assured that the forum will 40 D. A. Hoffman and K. Triantafillou be “judgment-free.” Victims of domestic violence satisfied with the adjudication process than with need judgments made about the abuser in order to mediation and “less likely to see the mediation disentangle themselves from a horrible situation. process as fair and unbiased” [9], while minority Thus, a mediated agreement may be “fair,” but as women were more satisfied with mediation. some authors point out, it may not be “just.” Furthermore, minority participants in mediation The impact of bias and power imbalance continued to express greater satisfaction with the described above with regard to gender can be process over time [10]. seen in the areas of race, ethnicity, culture, sexual orientation, age, religion, socioeconomic class, disability, and other factors that affect the media- Understanding Patterns tion process. Although empirical research about of Oppression and Discrimination this impact is still in its early stages, the results thus far suggest that diversity issues affect out- Discrimination in Negotiation comes in mediation. One of the frequently cited studies involved It is hardly surprising that diversity issues impact comparing the outcomes of adjudicated cases and the results of mediation. Discrimination has been mediated cases in the Bernalillo County a persistent feature of commerce in the United Metropolitan Court in Albuquerque, New Mexico States since our nation’s inception and before. [6]. Using approximately 600 cases, the Racial discrimination in housing and employ- evaluators attempted to discern whether women ment, for example, has been widely documented and minorities “would do more poorly … because long after the enactment of civil rights legislation mediation is a less formal, less visible, and less designed to end such practices. controlled forum than adjudication” [7]. The In one famous study of discrimination in the study focused on both subjective and objective commercial arena, reported in an article entitled outcomes and found that minority disputants Fair Driving: Gender and Race Discrimination in received less money than nonminority litigants in Retail Car Negotiations published by the Harvard adjudicated cases and mediated cases, with the Law Review, testers used a uniform negotiation latter being “more pronounced.” While some of strategy to bargain for the purchase of a new car the variation was due to other “case at 90 dealerships in the Chicago area [11]. The characteristics,” such as the claimant being a testers were white and black, women and men. lawyer or represented by a lawyer, the study The article’s author—economist, lawyer, and essentially concluded that mediated outcomes for business professor Ian Ayres—found that the minorities were less favorable than for offers made by salespeople were biased by both nonminorities. However, on subjective scales, the race and gender of the buyers (Table 3.1). such as satisfaction with the process, “minority Gender-based discrimination was also claimants were consistently more positive about convincingly demonstrated in studies involving mediation than they were about adjudication.” auditions for symphony orchestras. In 1970, What is most interesting about the study, however, is that the measured effects of bias in objective Table 3.1 Gender and race discrimination in car sales outcomes (less money received or more money White White Black Black paid) were dramatically altered if the mediators male female male female were members of the minority group—in other Average dealer 818 829 1534 2169 words, minority disputants achieved better results profit based on in mediations with minority mediators [8]. initial offers by the With regard to women, the study found that dealer ($) Average dealer 362 504 783 1237 gender had no direct effect on monetary out- profit based on comes, whether the case was mediated or adjudi- final offers by the cated. However, white women were more dealer ($) 3 Cultural and Diversity Issues in Mediation and Negotiation 41 female musicians comprised only 5% of the tage, but had been taught not to see one of its musicians in the top five symphony orchestras in corollary aspects, white privilege, which puts me at an advantage. the United States. Under pressure to increase this number, the orchestras instituted new procedures McIntosh continues her self-assessment with a involving the use of “blind auditions” in which list of the “daily effects of white privilege,” prospective performers played behind a screen so among them the following: that the judges could not see them. This produced a fivefold increase in the number of women who • I can go shopping most of the time, pretty well won places in those orchestras [12]. assured that I will not be followed or harassed. Race and gender are, of course, not the only • I am never asked to speak for all the people in factors that affect negotiations, hiring decisions, my racial group. and the way people treat each other. Research • If a traffic cop pulls me over or if the IRS has shown that physical appearance can produce audits my tax return, I can be sure I haven’t both positive and negative biases. Taller people been singled out because of my race. get paid higher salaries, on average, than short • I can take a job with an affirmative action people [13]. Unattractive people also face bias employer without having coworkers on the job in employment [14], and, according to one suspect that I got it because of my race. study, physical attractiveness can produce a sig- • If my day, week, or year is going badly, I need nificant boost in salary [15]. Even in the realm not ask of each negative episode or situation of criminal law, attractiveness plays a role: one whether it has racial overtones. study has shown that criminal defendants who • I can worry about racism without being seen are viewed as less physically attractive risk as self-interested or self-seeking. harsher sentences [16], Even within racial groups, physical appearance can affect sentenc- No one likes to think of themselves as biased, ing: “Analysis of a random sample of inmate but reading that list, or making up your own, records showed that Black and White inmates, certainly highlights the ways in which the lives given equivalent criminal histories, received of white people in our society differ from the roughly equivalent sentences. However, within lives of African-Americans, notwithstanding the each race, inmates with more Afrocentric fea- laws that prohibit discrimination of various tures received harsher sentences than those with kinds [19]. less Afrocentric features” [17]. The phenomena described above with regard Moreover, it is difficult for white people to to race apply with equal force in connection with deal effectively with their unacknowledged rac- gender, culture, sexual orientation, and other ism. The guilt attendant to such unexamined feel- characteristics. Although some indicia of dis- ings frequently clouds our perceptions and good crimination have improved (e.g., pay gaps intentions/actions. As much as we would like to between men and women have narrowed some- think we are “color blind,” if we grew up in the what), disfavored groups still suffer a variety of United States, we have racial baggage—regard- disadvantages in our society, and the favored less of our race. Professor Peggy McIntosh, a groups still, for the most part, struggle with women’s studies expert, makes the point quite acknowledgement of their advantages. effectively when she states the following in an There is a paradoxical aspect of cultural essay entitled White Privilege: Unpacking the competence for mediators—namely, that medi- Invisible Knapsack [18]: ators are trained to look forward, and yet to be I have often noticed men’s unwillingness to grant culturally competent requires an understanding that they are overprivileged, even though they may of the past and in particular the ways in which grant that women are disadvantaged … As a white oppression has shaped the experience, values, person, I realized that I had been taught about rac- beliefs, and emotional reactions of nondominant ism as something that puts others at a disadvan- groups. 42 D. A. Hoffman and K. Triantafillou

Internalized Oppression phenomenon was found when measuring the performance of women in chess matches in which Discrimination takes its toll internally, as well as the identity of the opponent was hidden from the externally. In the landmark school desegregation players [26]. In comparison to their rated strength, case of Brown v. Board of Education [20], the the women played worse when told that their Supreme Court cited as support for its opinion opponents were men and that men are better psychological studies showing that African- chess players than women. When women players American children had internalized a sense of were told that they were playing against women, inferiority—for example, preferring white dolls their performance improved, regardless of rather than dolls with darker skins and attributing whether their actual opponents were men or more positive characteristics to the white dolls. women. Based on this “doll test” and similar tests of chil- In another experiment, a group of African- dren, the studies concluded that prejudice, dis- American test-takers who were asked to indicate crimination, and segregation caused black their race at the beginning of the verbal portion of children to develop a sense of inferiority and self- Scholastic Aptitude Test performed substantially hatred. Citing this study with approval, the Court worse than a comparable group of African- stated that segregating black children from white Americans who were not asked to indicate their “solely because of their race generates a feeling race [27]. In other words, just reminding some- of inferiority as to their status in the community one of a racial difference may be a trigger that that may affect their hearts and minds in a way affects performance. In a similar test involving unlikely ever to be undone” [21]. Today, de jure math skills, asking Asian-American women segregation is illegal, but patterns of housing and questions that evoked consciousness of their race school assignment still relegate too many at the beginning of the test produced higher test African-Americans de facto to an essentially seg- scores, while asking them questions that evoked regated world. consciousness of their gender resulted in lower A related phenomenon is that of “internalized test scores [28]. homophobia,” experienced by lesbian and gay Internalized oppression can also produce individuals who internalize the prejudices of a physical effects. In 2007, The Boston Globe heterosexist society. “Stigmatized individuals reported on the growing body of evidence—more engage in defensive reactions as a result of the than 100 studies, most published since 2000— prejudice they experience and thus incorporate a showing the negative effects of racial discrimina- unique form of psychological distress” [22]. One tion on physical health, including heart disease of the obvious stressors is being “in the closet”; and stroke [29]. This phenomenon has been however, unlike other oppressed groups, LGBTQ found outside the United States as well [30]. An people also risk being shunned by their families epidemiologist at the Harvard School of Public or religious groups and must actively seek out Health, Nancy Krieger, found that these health new or alternative social networks that validate effects are worsened when the discrimination is their existence [23]. not discussed or addressed in some manner [31]. Another form of internalized oppression can For mediators, these studies suggest the be seen in a phenomenon known as “stereotype importance of addressing discriminatory behav- threat” [24], which can undermine the perfor- ior or comments when they arise. Sometimes mance of people who are members of groups that comments are made in mediation that the media- are negatively stereotyped [25]. This phenome- tor fears might be experienced by others as dis- non occurs even if there is no overt stereotyping criminatory even if they were not intended that taking place. According to several studies, stereo- way. Under those circumstances, the mediator type threat “undermines performance by creating could meet with the parties separately to assess distraction” and produces this effect in both labo- the situation and decide whether it seems advis- ratory and real-life settings. An example of this able to address this issue directly. 3 Cultural and Diversity Issues in Mediation and Negotiation 43

Culture and Negotiation 3. Personal styles (formal or informal?) 4. Styles of communication (direct or indirect?) In our discussion thus far, we have focused on the 5. Time sensitivity (high or low?) impact of difference in the context of bias and 6. Emotionalism (high or low?) oppression. Mediators, we conclude, need to be 7. Agreement form (specific or general?) keenly attuned to the impact of such differences 8. Agreement building process (bottom up or because of their potential impact on the media- top down?) tion process. For example, a party who feels 9. Negotiating team organization (one leader or demeaned by an opposing party because of his/ consensus?) her race, class, ethnicity, or gender, may “shut 10. Risk taking (high or low?) down” and find it hard to participate fully in the mediation. (In several sections below, we discuss Professor Salacuse measured responses from interventions that a mediator can use in such individuals in 12 countries [35]. The results situations.) reflect significant variations from country to In this section we focus on cultural differences country. Some of the results seem predictable. that do not always involve value judgments but For example, on Salacuse’s “informal or formal may engender misunderstanding if not under- scale,” 83% of the Americans interviewed felt stood. For example, in some cultures, eye contact they had an informal negotiating style as com- in a negotiation is considered aggressive, perhaps pared to 54% of the Chinese negotiators and 53% even offensive, while in other cultures the failure of the Spanish negotiators. Cultures that negoti- to make eye contact may be viewed as disrespect- ate similarly in one respect may diverge widely in ful [32]. These differences are akin to a differ- another—for example, on the scale of negotiation ence in eating utensils: chopsticks are neither attitude (win/win vs. win/lose), 82% of the inherently better nor worse than silverware—just Chinese negotiators describe their style as win/ different. A vast array of cultural differences can win, while only 44% of the Spanish negotiators complicate the work of peacemaking, if media- do. tors are not sensitized to those differences and While the complete results of this study are trained to deal with them effectively. too lengthy to include in this article, this brief Cultural competence requires us to learn or at description suggests why the participants in a least become familiar with the “silent language,” mediation session might be approaching the task as Jeswald Salacuse calls it, of other cultures of problem-solving differently based on their cul- [33]—a task akin to learning a foreign language. tural or ethnic background [36]. Even a reluc- We don’t, for example, try to change how the tance to participate in mediation could be an Russians decline nouns; we accept it and indication of a cultural attitude, such as the endeavor to become more adept at communicat- Korean-Americans studied by Diane LeResche, ing in that language. who view “conflict as a negative situation […] represent[ing] a shameful inability to maintain harmonious relationships with others” [37]. Negotiation Styles It is not always easy to know whether cultural issues are impacting mediation or whether a Professor Jeswald Salacuse focused his analysis mediator’s assumptions about cultural behavior strictly on negotiation and measured bargaining are getting in the way of successful communica- behavior, as reported by the negotiators, using the tion. Mistakes will be made! following matrix [34]: Along with complexities of negotiation style, mediators encounter a dizzying variety of com- 1. Negotiating goals (contract or relationship?) munication styles—many of them culturally 2. Attitudes to the negotiating process (win/win rooted. “Every country has its own way of saying or win/lose?) things,” according to the prolific travel writer 44 D. A. Hoffman and K. Triantafillou

Freya Stark. “The important thing is that which ferences, if not identified, become sources of lies behind people’s words” [38]. misunderstanding, judgment, and blame. Cataloguing specific cultural variations in Research reported by Dr. Pat Heim shows that communication style lies beyond the scope of these differences are not surprising, because boys this chapter. Suffice it to say, however, that an and girls grow up in different “cultures” with dif- astute mediator will be attuned not only to con- fering expectations about how to behave and how tent (e.g., is the style direct or indirect?) but also they will be treated [42]. These differences begin facial expressions, eye contact (or the lack of it), early in life. Infants wrapped in blue blankets are body language, and gestures. Figures of speech handled differently than infants wrapped in pink do not always translate well from one culture to blankets. The leading children’s books—those the next, and hand gestures can be particularly that have won the coveted Caldecott medal— tricky. (For example, a thumbs-up gesture in show ten males in positions of leadership for American culture means approval, but in Arab every female in such a role. The studies summa- cultures and South America, its meaning is vul- rized by Heim show that games that boys tend to gar [39]). play (war, cops and robbers, football) are essentially hierarchical, competitive, goal-oriented, and often team-based, while the games that girls Gender as Culture tend to play (dolls, house) are typically based on one-on-one connections, cooperation, and “flat” Researchers have long debated the question of (as opposed to hierarchical) relationships. whether male–female differences are learned or Although winning is the sole point in boys’ innate. For purposes of understanding and work- games, according to Heim, boys, on average, lose ing with those differences, however, their origin as often as they win and therefore learn to mask is probably irrelevant. What matters is how we their emotions, because showing sadness as a react to the parties in the mediation process and result of a loss would be considered “unmanly.” how they react to each other. (In the discussion In girls’ games, there tend to be no winners and that follows, gender is discussed based on what losers, and girls learn the importance of “being sociologists find as the center of the bell curve, nice” and “getting along” [43]. and, as in other descriptions of cultural norms, To be sure, the upbringing of girls and boys exceptions, and outliers abound.) has changed in the United States in recent years, Among recent conceptual breakthroughs in and today more girls than ever are involved in our understanding of how gender affects our competitive team sports (due in no small measure experience, perspectives, and social interactions, to the enactment of Title IX). However, social two stand out: Professor Carol Gilligan’s research scientists continue to see substantial differences about the development of ethical norms [40] and in how men and women behave, how they com- Professor Deborah Tannen’s research about gen- municate, and how they fare in business [44]. At der differences in the way people communicate the same time, these different “cultures” get [41]. Gilligan found that boys tend to develop blended to some degree as adults, since occupa- attitudes about ethics based on rule-based ideas tional roles influence behavior. For example, law of right and wrong, whereas girls tend to develop has often been described not only as a male-dom- attitudes that are more contextual and relational. inated profession (though this is changing) but Tannen found that women’s conversational styles also as a profession in which typically male were more personal, relational, and focused on “norms” hold sway. To use Gilligan’s typology, understanding, while men’s were focused more successful arguments in the legal arena are typi- on information, advice, and status/power. Neither cally based on rules of general applicability (and Gilligan nor Tannen argued that the norms of one concepts of right and wrong) rather than contex- gender are “better” than the other’s (quite the tual and relationship-based norms. opposite)—instead, their point was that these dif- 3 Cultural and Diversity Issues in Mediation and Negotiation 45

The bottom line, as we try to understand the typical negotiating behavior, the mediator con- ways in which gender operates as a “cultural” dif- cludes (probably inaccurately) that the employee’s ference, is that one culture is not better than the bargaining style is atypical because of cultural dif- other. Chopsticks are not better than silverware, ferences. The mediator encourages the employee to nor is it essential that one culture learns to use the follow the lead of his attorney, who is very experi- utensils of the other. Rather, the point—for media- enced in employment cases, but the employee tors and others—is to destigmatize the difference. resents this advice, fires his lawyer, and arrogantly The LGBTQ movement has also expanded asserts that he is a better negotiator than anyone society’s understanding of what gender means involved in the case and therefore does not see why and how it relates to sexual orientation and he should follow anyone’s advice. In the end, the human biology. According to traditional views on mediator concludes (after consulting with a psy- these subjects, gender and sexual orientation are chologist) that the employee’s behaviors indicate binary: one is either male or female, and one is the possibility of a narcissistic personality disorder. attracted to men or to women. A more nuanced In this case, culture no doubt played a role in and accurate view is that there are at least four the negotiations. But because culture was the components: (a) biological sex (based on physi- most obvious difference, it obscured a less visible cal characteristics); (b) gender identity (how we but arguably more powerful factor—namely, a think about ourselves on a scale that ranges from psychological issue that stood in the way of pro- “woman” to “man” with “gender queer” in the ductive bargaining. middle of the scale); (c) gender expression (how Social dynamics can also play a role. In most we express ourselves by how we dress, behave, mediations, the parties are not alone—they are and interact); and (d) sexual orientation (to whom part of a social matrix that influences their bar- are we attracted). This broader understanding has gaining behavior. In divorce mediations, for also led to the use of the term “cis-gender,” which example, each spouse usually receives advice and (a) means that a person’s gender identity corre- encouragement from an assortment of friends sponds to their sex assigned at birth and (b) is the and relatives, not to mention professional advice opposite of transgender [45]. from lawyers and therapists. Not surprisingly, the parties feel accountable to some degree to these constituencies of supporters. Thus, while the Confounding Variables: Psychological mediator tries to understand the unique aspects of Issues and Social Dynamics each of the parties (cultural, gender, psychological, or other), s/he may not realize that there are a One of the joys of mediation is its inherent host of other people in the wings, each with their complexity. For people who enjoy challenges, it own complicated backgrounds and psychological is an ideal occupation. The challenges presented orientations. To the extent that each of the parties by diversity issues are compounded when we in the mediation is driven by a desire not to lose take into account the psychology of the parties face with these supporters, it becomes necessary (and our own) and the social dynamics that for the mediator to understand the cultural orien- influence behavior in the setting of mediation. tation and goals of those supporters. A case in point: a middle manager is fired by his Another case in point: a college freshman has employer for abrasive communications with his died in a fraternity hazing incident, and his parents colleagues and supervisors. He sues the employer, are now suing the fraternity, its parent organiza- alleging national-origin discrimination (he is from tion, the owner of the fraternity’s building, several Eastern Europe). In the mediation of this dispute, individuals involved in the incident, and all of the the employee negotiates in a manner that seems relevant insurers. The family is demanding $10 unusual to the mediator. The employee lowers his million as a settlement. The mediator is meeting demand and then raises it again. Operating from a with the defendants—11 parties in all. Everyone in framework of North American assumptions about the room agrees that their initial offer of settlement 46 D. A. Hoffman and K. Triantafillou needs to be no less than $1 million, or else the Developing Cultural Competence plaintiffs will likely terminate the mediation. When each party is asked what they are willing to One obvious place to start is to look within. offer in this first round of negotiation, the collec- Acknowledgement and self-assessment help us tive sum is only $900,000. All of the defendants clear our minds of judgments about the parties. agree that it would be in their best interest to come Bias arises from learned attitudes and can be up with another $100,000 in order to keep the transmitted to those close to us or part of our mediation on track, but no amount of reasoning group. And what can be learned, can be and cajoling from the mediator breaks this dead- unlearned. This conclusion was documented in lock. The mediation ends, and the case proceeds to fMRI studies reported by the developers of the litigation. Why were the defendants deadlocked? Implicit Association Test (“IAT”), an ongoing The mediator concludes that there were two sets of study sponsored by Harvard University [46]. social dynamics that overwhelmed rationality. Visitors to this site have completed more than 4.5 First, in the conference room, each of the defen- million tests [47], which explore their reactions dants was seeking to communicate its resolve to to people based on their race, age, gender, weight, the other defendants. Even though there was virtu- disability, and other characteristics. Based on this ally no chance that the defendants’ initial offer data, researchers have found, among other things, would be accepted, none of the defendants wanted that 80% of Americans harbor negative attitudes to “blink,” because of the precedential effect that toward the elderly and 75–80% of the white and could have been had in subsequent rounds of bar- Asian test-takers express preferences for whites gaining. Second, and equally important, all of the rather than blacks. The developers of the IAT defendants (and particularly the corporate defen- found that while we have automatic, immediate, dants and insurers) were merely representatives of unconscious reactions to people of a different complex organizations with their own unique cul- race at the level of our amygdalas, those responses tures and values. These representatives may have (not surprisingly) can be moderated by other felt that they needed to avoid losing face with their parts of our brain that regulate our social interac- constituencies back at the office. (One common tions [48]. (The test gives new meaning to the observation about negotiation dynamics is that the expression, “The truth shall make ye free, but toughest bargainers are those who are farthest first it shall make ye miserable.”) from the table.) Recognizing that bias is a universal In short, mediators need to remember that, phenomenon can lead us to both self-criticism even if they believe they understand how culture, and self-forgiveness. Both of these seemingly class, race, ethnicity, gender, sexual orientation, contradictory impulses are valid responses to the and other factors may be influencing the individ- residue of bias that lingers in even the most con- ual parties in the room, each of the parties may scientious and culturally competent mediators. also be influenced by unseen psychological and When Harvard psychology professor social dynamics involving people who are not Mahzarin Banaji developed the IAT with psy- present. Accordingly, mediators should inquire chologist Anthony Greenwald, she was surprised about those dynamics and try to understand how to find that she was biased against blacks—a par- they are affecting the mediation process. ticularly vexing phenomenon because she herself is a person of color. One of the techniques that she used to counteract her own implicit attitudes Practical Considerations with regard to both race and gender was to dis- for the Mediator play prominently in her office photographs of women and people of color whom she admired— Given what we know about bias, how can the George Washington Carver, Emma Goldman, well-intentioned mediator guard against it both Miles Davis, Marie Curie, Frederick Douglass, personally and with clients? and Langston Hughes [49]. 3 Cultural and Diversity Issues in Mediation and Negotiation 47

Perhaps an even more profound change may Finally, mediators need to bring enough come from widening and deepening the circle of humility to their work to be open to the possibil- connection in each of our lives. All too often, ity that some other mediator might be a better fit those in our circle of friends and colleagues look for the parties because of background or experi- a lot like us. Mediators can make a conscious ence. (Also, see discussion below regarding choice of involving a wider circle of colleagues co-mediation.) in our professional work through self-reflection and peer supervision groups. And even within our existing circles of friends and colleagues, we The Mediator’s Relationship often fail to explore deeper levels of understand- with the Parties ing of people who are different from us. Here is an exercise in overcoming our own An enigmatic story from Professor Michelle implicit bias described by Professor Banaji: LeBaron about an informal mediation in a First Just before Halloween, Banaji says, she was in a Nations community in Canada captures one Crate & Barrel store when she spied a young aspect of what mediators need to know to prac- woman in a Goth outfit. The woman had spiky hair tice in a culturally competent manner: that stuck out in all directions. Her body was pierced with studs. Her skull was tattooed. Banaji's instant reaction was distaste. But then she remem- • There was an elder who had a dog, and that bered her resolution [to engage with people she dog barked all night long, every night, kept the might otherwise have avoided]. She turned to make whole neighborhood awake. It was a really eye contact with the woman and opened a conversation [50]. yappy dog, and nobody could stand it much longer. One afternoon an elder went over to Cultural competence involves more than freeing visit the dog owner without being announced. our minds of bias—it requires affirmatively seek- They had tea. Talked about the weather and ing to understand the people we encounter in the the upcoming powwow. They told a couple of mediation process and elsewhere. Curiosity is key. stories. Then the elder left. Still the dog barked If participants are from a country or ethnic group at night. A few days later, the same elder outside your experience, spend some time reading dropped by for another visit. Same thing. They about that culture [51]. If the person’s background talked about the weather and the brushfire or ethnicity is not apparent, do not be afraid to ask down in the coulee. Then the elder left. Still background questions that will aid your work. no relief. A day or two later, the elder visited Avoid stereotypes—for example, do not assume again. They had tea. Talked about the weather, that all people from a particular country or culture the way the government negotiations were are likely to have the same negotiating style. going. And the elder left. After that, the dog Respect for the parties is a crucial element of was kept in every night. Never caused any- cultural competence. One key element of such body trouble anymore [52]. respect is pronouncing the parties’ names cor- rectly and adopting a form of address that is com- Why did the two elders never discuss the dog? fortable. Many mediators prefer working with the And how did the dog owner finally come to parties on a first-name basis, because the infor- understand what was being asked of him/her— mality contributes to a spirit of collaboration. albeit inexplicitly? The essential element of the However, first-name basis may be profoundly success of this intervention appears to be the rec- uncomfortable for people who are accustomed to ognition that the dog owner needed to avoid los- a more formal manner of addressing people in a ing face in the community, and therefore direct business setting. And it might also be uncomfort- confrontation about the dog might have been able to people who, because of cultural or power counterproductive. This story suggests that in dynamics, have felt demeaned when called by this particular culture, a gentler, less direct form their first names. of negotiation was needed. A mediator who 48 D. A. Hoffman and K. Triantafillou lacked an understanding of this feature of the par- An even more challenging dilemma arises when ties’ culture might have been more direct and less one of the parties says or does something in the successful. mediation that has the unmistakable ring of bias, However, given the enormous variety of condescension, or disrespect. The mediator has a cultural and diversity issues that can arise in a number of choices—the following are only a few mediation, how can a mediator manage those of the options. First, s/he can decide to ignore the differences successfully? event for the time being, hoping that the negotiation will stay on track and perhaps revisiting the incident later with the parties separately or together. Premediation Consultation, Second, s/he can intervene in the moment by call- Planning, and Research ing attention to what s/he saw or heard, and either lodging his/her objection or inquiring about what Mediators should generally consider and, in some the action or comment was intended to communi- cases, insist on a premediation consultation with cate. Third, s/he can inquire of the party who was the parties. In addition to such logistical consider- the object of the action or comment, to find out ations as who will be attending, how much time to what impact it may have had. Finally, the mediator reserve, and how the mediation fee will be allo- can call for a break and discuss what occurred with cated, mediators can ask about the parties, their each of the parties. None of these courses of action backgrounds, and other information about them will be right for every case. And it is, of course, that will help the mediator prepare for the case. challenging to consider these options and others These separate meetings provide an excellent (and their respective advantages and disadvan- opportunity to explore diversity issues in a safer tages) in the split-second in which a timely deci- setting. In family mediation, meeting separately sion must be made. To some extent, the mediator with the parties can uncover power dynamics and must use his/her intuition, and then be self-forgiv- cultural differences. The Internet also provides a ing if the judgment proves to be unsound. vital opportunity to learn about the parties, their And what if the offensive remark is directed at values, and their backgrounds. the mediator? The critical decision for the mediator is whether a response is needed for reasons related Confronting Bias to the mediation itself. There are occasionally situations—particularly in joint sessions—where As noted above, one of mediation’s central tasks offensive, disrespectful, or bullying behavior is making a safe place for a difficult conversation. directed toward the mediator must be addressed If any of the parties feels demeaned—particu- in order to foster a feeling of safety for the other larly as a result of his/her culture, class, ethnicity, participants in the mediation. Even in those situ- gender, race, sexual orientation, disability, or ations, for example, there are choices to be made other characteristics—the mediation will no lon- about how to address the offensive action of ger feel safe. How, then, can a mediator prevent remark. For example, speaking separately to the or respond to behavior that causes the mediation offender might elicit an apology that could defuse to feel unsafe in this way? the tension and possibly even create some positive As noted above, preparation can sometimes momentum toward settlement. head off trouble at the outset, by alerting the mediator to the relevant risks. The mediator might be informed that one of the parties is con- Validating Differences sidered a bigot by the other parties. Or that one of and Commonalities the parties has a hard time treating women as equals. What might the mediator do in a separate One of the key concepts in negotiation theory is meeting with one or more of the parties to neu- that the parties’ differences create opportunities tralize potentially disruptive behavior? for joint gains. In the classic example of dividing 3 Cultural and Diversity Issues in Mediation and Negotiation 49 an orange, described in the book Getting to Yes, torial conflicts between tribes was to gather for the fact that one child wanted to make juice and negotiation, which could only begin after the the other wanted only the rind for a cake created tribes have (a) discussed their lineage and the the opportunity for each to have the equivalent of times in the past when their ancestors had helped a whole orange [53]. Culturally competent medi- each other; (b) named those in their respective ation means striking the balance between tribes who had passed away; and then (c) shared acknowledging and validating the parties’ differ- a meal together [54]. Such elaborate rituals are ences when they are relevant and at the same time ill-suited to modern mediation, but acknowledg- looking for common ground. ment of common experience (e.g., the loss of How does this work in practice? A case in loved ones) or the sharing of a meal can some- point: an elderly African-American janitor was times help to bridge gaps that initially might suing his employer for race discrimination in seem insurmountable. terminating him. As the mediation began, the mediator asked if the parties were comfortable addressing each other on a first-name basis. The Mediating Values-Based Conflict janitor said, “I prefer that you call me Mr. Jones.” In the course of the mediation, he dis- Among the most profound differences that cussed his background as a sharecropper and the mediators encounter are those based on deeply way that he was addressed as “boy” long into held values—sometimes fueled by religious or his adulthood. The central issue of the media- political beliefs. For example, in the conflicts tion thus became whether a settlement could be over abortion, advocates on both sides of the reached that did further strip this gentleman of controversy are unlikely to find common ground, his dignity. The fact that his life experience and neither believes that a compromise is morally made him different from everyone else in the acceptable [55]. Moreover, the values and beliefs room could have been downplayed, but instead that fuel this controversy are unlikely to yield to it was acknowledged by the mediator without persuasion. condescension. The mediation resulted in Mr. MIT Professor Lawrence Susskind has Jones being reinstated in exchange for his with- identified four methods for addressing values- drawing his suit, but the most memorable aspect based conflict: (a) focusing on interests and of the mediation, he said, was that he was treated values separately (e.g., the parties might achieve as an equal in the mediation room. That a mutually beneficial détente without having to acknowledgment and reinstatement were worth resolve their differences regarding values); (b) more than a monetary settlement from Mr. shift the goal of the mediation from resolution Jones’ standpoint. to dialogue, seeking to increase mutual under- A key element for the mediator is sensitivity standing; (c) identify one or more overarching to the following question: how does each person values on which the parties agree and that enable feel about his/her difference being acknowledged the parties to transcend the conflict; and (d) con- or treated as irrelevant? The answer to this ques- front values directly with the goal of reconciling tion may be far from obvious, and the answer the differences [56]. may change over time as the mediation unfolds. In some cases, one or more of the parties may Taking breaks in the mediation for caucus ses- couch their differences as a matter of principle— sions creates an opportunity to address such for example, “I refuse to negotiate with a liar, as questions and thus keep the mediation on track. a matter of principle.” In such situations, the par- Another key element for the mediator is ties do not disagree about values—both sides recognizing that people have far more in common would readily agree that lying is blameworthy. than often meets the eye. Identifying those com- Instead, the dispute is more accurately described mon elements of the human condition can some- as one in which one of the parties fears exploita- times open the door to resolution. Among Maori tion or is dug in because of anger over perceived tribes, the traditional method for resolving terri- exploitation in the past, or both. 50 D. A. Hoffman and K. Triantafillou

Co-mediation as a Technique ment—s/he simply recounts what happened and for Leveling the Playing Field how the teller experienced that history. Narrative is not a magic bullet. But in The parties in a mediation often wonder if the appropriate cases, it can unlock the door to mediator can truly be impartial. This concern is resolution and understanding diversity. heightened if, for example, the mediator is the One of the best case studies in the literature of same race, gender, or ethnicity as one of the par- mediation—mediator Carol Liebman’s Mediation ties but not the other. In divorce mediation with as Parallel Seminars: Lessons from the Student heterosexual couples, co-mediation—with one Takeover of Columbia University’s Hamilton male and one female mediator—is often used. In Hall [57]—tells a story of co-mediation. The stu- a recent sexual harassment case, the female plain- dents—primarily, but not exclusively, students of tiff asked the male mediator if he would be will- color—were demanding the creation of an Ethnic ing to have a woman co-mediator; the answer Studies Department at Columbia. Liebman, who was yes, and the case quickly settled. Adding a teaches mediation at Columbia, was asked to co-mediator does not mean that a solo mediator mediate the conflict despite her position as a fac- could not be impartial. However, from the stand- ulty member, but, because she is white, she point of feeling heard and understood, the par- sought out a minority co-mediator, political sci- ties’ preference to have one of the mediators be entist Carlton Long, and the two of them success- someone with a background or characteristics fully mediated the conflict. similar to theirs makes sense and has proven to be One of the valuable insights from Liebman’s a successful strategy for settlement in mediation. account of the mediation is the metaphor of par- Co-mediation also adds value for the mediators. allel seminars, which captures three important Drawing on the experience, skills, expertise, and aspects of the case. First, the idea that mediation perspectives of two people who have different involves education, not only for the mediator, approaches and have worked in different contexts who is learning about the dispute, but also for the will add to the diagnostic range and the variety of parties, who may be unfamiliar with the process tools needed to handle complex conflicts. This is of mediation and interest-based negotiation. particularly true in situations involving diversity Second, the idea that these seminars can take of race, culture, class, gender, and other place separately—in parallel—when the tensions characteristics. between the parties, as in this case, run so high that the parties are unwilling, for the most part, to participate in joint sessions. Finally, the idea that The Power of Narrative in situations where diversity issues are present, there is yet another important layer of learning Discussing diversity issues in mediation, as in that is underway, as the mediators and the parties other settings, can be fraught with emotion. For try to understand the identity-based and value- those who have been subjected to discrimination, based issues that are driving the conflict. seeking to be understood on the subject of bias Because we can never entirely walk in each may arouse feelings of vulnerability. For those other’s shoes, diversity issues require of media- who have enjoyed the benefits of majority status, tors an ongoing openness to learning and a com- the same conversation may evoke feelings of mitment to bringing “beginner’s mind” into every defensiveness. These two reactions can feed each mediation. Even when diversity issues are not other, fostering a cycle of blame and denial. present, the idea of the parties and mediator edu- In order to break that cycle, mediators have cating each other is a valuable model for the found that personal narrative can be a powerful mediation process [58]. In the mental health pro- tool for understanding. Narrative can overcome fessions, this aspect of the process might be argument, because the teller is not seeking agree- referred to as psychoeducation. 3 Cultural and Diversity Issues in Mediation and Negotiation 51

Welcoming Diverse Practitioners For all of these reasons, it is incumbent upon to the Field of Mediation those who seek to advance the use of mediation broadly throughout the United States to take Attend almost any conference of mediators in the affirmative steps to invite and include minority United States, and you might wonder: where are mediators. the people of color? [59] For reasons described in this chapter, mediation can be more effective in resolving conflict if the ranks of mediators reflect Conclusion the diversity of our society. There appear to be at least three reasons for Becoming a culturally competent mediator is a the underrepresentation of minorities in the process, not a destination. The complexity of the mediation field. First, minorities are underrepre- task of mediation is multiplied severalfold by the sented in the occupations from which many diversity of people that mediators encounter. mediators—perhaps even a majority—come. The Cultural competence requires a form of learning following census figures for 2017 tell that story, that is not only intellectual but also lodged in the which has improved a bit, but only a bit, in recent heart. Compassion and empathy are as vital as years (Table 3.2) [60]: curiosity and an open mind. Subtle, and not so subtle, headwinds retard progress of non-whites in these professions. It was not until 1943, for example, that non-white References lawyers were even allowed to join the American Bar Association. 1. Rule 1(b)(vii) provides: “The policies, procedures and providers of dispute resolution services should reflect Second, mediation is still a relatively new the diverse needs and background of the public” phenomenon. Making a living as a mediator can (emphasis added). And Rule 7(b) (“Diversity”) be extraordinarily difficult. In minority commu- provides: “Programs shall be designed with knowledge nities in the United States, the individuals who of and sensitivity to the diversity of the communities served. The design shall take into consideration such achieve the level of education required for work factors as the languages, dispute resolution styles, as a professional may be among the first in their and ethnic traditions of communities likely to use the families to do so. The risk—both social and eco- services. Programs shall not discriminate against staff, nomic—involved in using that education on a neutrals, volunteers, or clients on the basis of race, color, sex, age, religion, national origin, disability, relatively unconventional occupation can be a political beliefs or sexual orientation. Programs formidable obstacle. shall actively strive to achieve diversity among staff, Finally, the lack of minority participation in neutrals, and volunteers” (emphasis added). mediation can become a self-fulfilling prophecy, 2. See Fiss O. Against settlement, Yale LJ. 1984;93(6):1073; Delgado E. Fairness and formality: as the field of mediation looks less appealing to Minimizing the risk of prejudice in alternative dispute would-be minority mediators until there is a criti- resolution. In: Alfini J, et al. editors. Mediation cal mass of people of similar background. theory and practice. 2nd ed. New York: LexisNexis; 2006. p. 360: “The risk of prejudice is greatest when a member of an in-group confronts a member of an out-group; when that confrontation is direct, rather Table 3.2 Underrepresentation of minorities in selected than through intermediaries; when there are few professions rules to constrain conduct; when the setting is closed US and does not make clear that ‘public’ values are to population Lawyers Psychologists preponderate; and when the controversy concerns an (%) (%) (%) intimate, personal matter rather than some impersonal African- 12.1 5.6 6.5 question…”. American 3. Grillo T. The mediation alternative: process dangers for women. In: Alfini J, et al., editors. Mediation Asian 6.2 4.4 3.6 theory and practice. 3rd ed. New York: LexisNexis; Hispanic 16.9 4.8 8.5 2007. p. 362. 52 D. A. Hoffman and K. Triantafillou

4. Kolb D, Coolidge G. Her place at the table: a 24. Steele, C. & Aronson, J., Stereotype threat and the consideration of gender issues in negotiation. In: intellectual test performance of Affrican Americans, Breslin JW, Rubin JZ, editors. Negotiation theory J Pers Soc Psychol, 1995, vo. 69, no.5 (797–811). and practice. Cambridge, MA: Harvard Law School; 25. Walton GM, Spencer SJ. Latent ability: grades and test 1991. p. 261, 265, 269. scores systematically underestimate the intellectual 5. Babcock L, Laschever S. Women don’t ask. Princeton, ability of negatively stereotyped students. Psychol NJ: Princeton University Press; 2003. p. 172. Sci. 2009;20(9):1132–9. 6. Herman M, et al. An empirical study of the effects 26. Maass A, D’ettole C, Cadinu M. Checkmate? The of race and gender on small claims adjudication role of gender stereotypes in the ultimate intellectual and mediation. In: Alfini J, et al., editors. Mediation sport. Eur J Soc Psychol. 2008;38(2):231–45. theory and practice. 2nd ed. New York: LexisNexis; 27. Steele CM, Aronson J. Stereotype threat and the 2006. p. 371–7. intellectual performance of African Americans. J Pers 7. Id.at 372. Soc Psychol. 1995;69(5):797. 8. The same was not true if one of the two mediators was 28. Shih M, Pittinksy T, Ambady N. Stereotype white. susceptibility: identity salience and shifts in 9. Herman, supra note 8, at 374. quantitative performance. Psych Sci. 1999;10(1):80; 10. Id. (Significantly, women mediators were more see also Kray LJ, et al. Stereotype reactance at the successful in reaching agreement in mediation than bargaining table: the effect of stereotype activation their male counterparts.) and power on claiming and creating value. Personality 11. Ayres I. Fair driving: gender and race discrimination Soc Psychol Bull. 2004;30(4):399, 400–401 in retail car negotiations. Harvard L Rev. 29. Drexler M. How racism hurts—literally, the Boston 1991;104(4):817. globe. 2007 July 15; Sect. E:1. 12. Goldin C, Rouse C. Orchestrating impartiality: the 30. “Race, Racism and Health.” Report, Robert Wood impact of “blind” auditions on female musicians. Am Johnson Foundation, May 8, 2018. https://www. Econ Rev. 2000;90(4):715. rwjf.org/en/library/collections/racism-and-health. 13. Judge TA, Cable DM. The effect of physical height on html. workplace success and income: preliminary test of a 31. See Krieger N. Discrimination and health inequities. theoretical model. J Appl Psych. 2004;89(3):428. Int J Health Services. 2014; 44:643–710. 14. See generally Rhode D. The beauty bias: the injustice 32. Spoelstra M Negotiation across cultural boundaries. of appearance in life and law. New York: Oxford Negotiation Academy; 2011. University Press; 2010. 33. Salacuse JW. Ten ways that culture affects 15. Rhode D. Prejudiced toward pretty. National LJ. 2010 negotiating style: some survey results. Negotiation J. May 3 (“In a famous study, ‘Lawyers’ Looks and 1998;14(4):223–4. Lucre,’ economists Jeff Biddle and Daniel Hamermesh 34. Id. estimated that attractiveness may account for as much 35. The United States; the United Kingdom; France; as a 12 % difference in attorneys’ earnings.”) Germany; Spain; Mexico; Argentina; Brazil; Nigeria; 16. Gunnell JJ, Ceci SJ. When emotionality trumps India; China; and Japan. reason: a study of individual processing style and 36. Cultural indicators, of course, can also be found juror bias. Behav Sci Law. 2010;28(6):850. domestically in various non-ethnic groups, such as 17. Blair IV, et al. The influence of Afrocentric facial the LGBTQ community, in which there are a number features in criminal sentencing. Psychol Sci. of sub-cultures as well (such as gay male, lesbian, and 2004;15(10):674–9. transgender communities). 18. McIntosh P. White pr 2). 37. LeResche D. A comparison of the American mediation 19. For a recent, highly acclaimed historical account of process with a Korean-American harmony restoration the treatment of African-Americans’ migration to the process. In: Mediation and negotiation: reaching North and West in the 1900s, see Wilkerson I. The agreement in law and business. 2nd ed. New York: warmth of other suns. New York: Random House; LexisNexis; 2007. p. 197. 2010. An effective treatment of anti-Muslim bias in 38. Freya S. The journey’s echo. In: The peace corps the United States post-9/11 is Eggers D. Zeitoun. San cross cultural workbook. p. 75, [Internet] [cited 2012 Francisco: McSweeney’s; 2010, which is a personal Dec 3]. Available from: https://files.peacecorps.gov/ account of events following Hurricane Katrina in New multimedia/pdf/library/T0087_culturematters.pdf. Orleans. 39. Salacuse JW. Negotiating: the top ten ways that culture 20. Brown V. Board of education. 347 U.S. 483; 1954. can affect your negotiation. Ivey Business Journal; 21. Id. at 494 & n.11. 2004. https://iveybusinessjournal.com/publication/ 22. Williamson IR. Internalized homophobia and health negotiating-the-top-ten-ways-that-culture-can-affect- issues affecting lesbians and gay men. Health Educ your-negotiation/. (Section 4). Res. 2000;15(1):97–106. 40. See Gilligan C. In a different voice: psychological 23. Yoshino K. Covering; 2006. theory and women’s development; 1993. 3 Cultural and Diversity Issues in Mediation and Negotiation 53

41. See Tannen D. You just don’t understand: women and 50. Id. men in conversation. 2nd ed. New York: Ballantine 51. Steele R. Understanding culture in mediation. Books; 1991. Mediate.com – Find mediators – World’s Leading 42. See Heim P, Murphy S, Golant SK. In the company Mediation Information Site; 2015. www.mediate. of women: Indirect aggression among women (2003); com/articles/SteeleR1.cfm. Videotape: The Power Dead-Even Rule and Other 52. LeBaron M. Bridging troubled waters: conflict Gender Differences in the Workplace (Dr. Pat Heim resolution from the heart. San Francisco: Josey-Bass; Series1995). 2002. p. 245. 43. Heim P, Murphy SA, Golant S. In the company 53. Fisher R, Ury W. Getting to yes; 1981: ch. II(4). of women: indirect aggression among women. 54. Roth S. LICSW, who has studied Maori customs in New York: Penguin Group; 2003. p. 84–106. connection with her travels in New Zealand. 44. Mulac A, Bradac JJ, Gibbons P. Empirical support 55. Fowler A, Gamble NN, Hogan FX, Kogut M, for the gender-as-culture hypothesis: an intercultural McComish M, Thorp B. Talking with the enemy. The analysis of male/female language differences. Human Boston Globe, 2011 Jan 28; Sect. F:1. Comm Res. 2001;27(1):121. 56. Susskind L. How to negotiate when values are at 45. For a useful discussion of these concepts, see stake. Negotiation; 2010 Oct. Killerman S. The Genderbread Person. http:// 57. Liebman C. Mediation as parallel seminars: lessons itspronouncedmetrosexual.com/2015/03/ from the student takeover of Columbia University’s the-genderbread-person-v3/. Hamilton Hall. Negotiation J. 2000;16(2):157. 46. This implicit attitude test. Available from: http:// 58. Mnookin R. Bargaining with the devil: when to www.implicit.harvard.edu. negotiate, when to fight. New York: Simon & 47. Weissberg R. Pernicious tolerance: how teaching to Schuster; 2010. p. 177–208. ‘accept differences’ undermines civil society: Google 59. A notable exception is the annual conference of Books, Transaction Publishers; 2008. https://tinyurl. the Center for Alternative Dispute Resolution in com/ycdlsqov. p. 102. Maryland. http://www.natlctr4adr.org. 48. Stanley D, Phelps E, Banaji M. The neural basis 60. Bureau of Labor Statistics. Employed persons by of implicit attitudes. Curr Directions Psych Sci. detailed occupation, sex, race, and Hispanic or Latino 2008;17(2):164. ethnicity [2017]. Available from: https://www.bls. 49. Vedantam S. See no bias. The Washington Post. 2005 gov/cps/cpsaat11.htm. Jan 23; Sect W:12. Providing Medical Care to Diverse Populations 4

Deborah Washington and Robert Doyle

If we are to achieve a richer culture, richer in contrasting values, we must recognize the full gamut of human potentialities. (Margaret Mead)

Introduction tion provided is focused on the healthcare environment, the concepts discussed are relevant to It is not yet evident how strong of an influence educators, diversity trainers, and professionals diversity holds on clinical decision-making or from other social sciences. quality of care. What remains unclear is the manner in which disparate patient characteristics function. The associated cognitive procedures are Background complex. Affordable care, access to care, and compliance with recommended treatment are The demographic shift of the American popula- examples of factors that influence health out- tion from majority White to majority-minority is comes, but fail to provide a definitive explanation fast approaching. The boomer generation is for variations that deviate from the norm. majority White, and those younger than 35 are Explanations for these differences are lacking. predominantly ethnic minorities [1]. The cultural The capacity for race and ethnicity to influence and linguistic profile of the immigrant population treatment and resource allocations, for example, as of 2016 shows a non-European entrance into is a decision process open to interpretation. This the country. The Migration Policy Institute reports is problematic because the ability to evaluate a that while most people under 5 years old living in clinical decision requires understanding the many the United States describe speaking only English interrelated elements that contribute to judgment. at home (78%), the rest of the population speaks In the end, there exists the need to evaluate clini- Spanish, Chinese, Tagalog, Vietnamese, Arabic, cal choices and to understand the extent to which or French [2]. More than half of the immigrant patient attributes have the power to influence population has private healthcare coverage, and those determinations. This chapter will tackle the approximately 30% has public health insurance. challenge of what it means to provide culturally Immigrants and refugees face stress-related men- sensitive healthcare to arguably the most diverse tal health issues linked to their life situation, the population on the planet. Although the informa- need to acculturate to US culture, encounters with discrimination, and experiences with trauma [3]. Economic hardship and loss of status complicate D. Washington (*) · R. Doyle the process of settling into an expatriate life. Department of Psychiatry, Massachusetts General Greenberg [3] outlined barriers to accessing Hospital, Boston, MA, USA e-mail: [email protected]; mental health services for the immigrant popula- [email protected] tion. They include:

© Springer Nature Switzerland AG 2019 55 R. Parekh, N.-H. T. Trinh (eds.), The Massachusetts General Hospital Textbook on Diversity and Cultural Sensitivity in Mental Health, Current Clinical Psychiatry, https://doi.org/10.1007/978-3-030-20174-6_4 56 D. Washington and R. Doyle

• Differences in symptom expression, under- States. The channels of service to persons on the standing etiology and effective coping edges of society, compared to those available to mechanisms the dominant social group, did not reflect parity. • Stigma of mental illness But who can possibly be an expert on so many • Language barriers and lack of interpreters diverse cultures that converge in waiting rooms • Patient-provider cultural concordance across this country 24 h a day? • Fear and mistrust of the healthcare system

As the United States goes through a ground Health Disparities swell of change in healthcare delivery, one fact remains unchanged: the population of patients The existence of inequitable treatment provided treated will be more diverse. The country known to patients with dissimilar sociodemographic as the melting pot of the world grew to its current details is one of the great ethical and analytic status as a world leader due to the influx of new challenges in modern healthcare. Present-day notions and confluence of diverse cultures that research is a helpful means for sharing current challenged the status quo and pushed the enve- thinking on variations in health status and the lope of possibility. Whether we talk about a jazz outcomes of health management as they relate funeral stepping to the beat of Louis Armstrong’s specifically to ethnic populations. Contributing syncopated rhythms or Neil Armstrong’s “One factors highlighted in the literature are socioeco- small step,” no one doubts that America placed an nomic realities, flawed systems, or inadequate indelible imprint on the modern world. Although training in cultural competency. Relevant to the America met President Kennedy’s challenge to last contributing factor of cultural competence, land a man on the moon and return him safely to English proficiency, socioeconomic status, gen- earth, decades later we still struggle to under- der, sexual orientation, cognitive or physical abil- stand the man or woman standing next to us on ity, and religious or spiritual belief systems are terra firma. If one considers the number of cul- inherently neutral social classifications that take tures and subcultures that coexist in America, the on added dimension when linked with stigma- complex calculations to go to the moon and back tized or marginalized social groups. English pro- might seem relatively easy math compared to the ficiency and Hispanics, socioeconomic status and many permutations of culture in our society. Blacks, or religion and Muslims are life charac- This acknowledgment becomes increasingly teristics that may be variables or proxies for yet important within the context of the national dia- another unidentified process when examining the logue on health disparities and unequal treat- intricacies of disparities in healthcare. ment. The 2002 Institute of Medicine (IOM) One of the most challenging possibilities is report entitled, Unequal Treatment: Confronting that health outcomes for diverse groups are Racial and Ethnic Disparities in Health Care, impaired by bias in clinical decision-making. The repudiated the assumption that the American integration of stereotypes, for example, into the health delivery system was fair and equitable. A information schema that health professionals cornucopia of questions related to quality of care maintain about minority patients raises questions and access to care for groups on the social mar- that healthcare researchers can evaluate and gins followed the groundbreaking study in quick understand. The implications for the provider and succession. The synthesis of research exempli- the patient are basic and fundamental: perfunc- fied by the report moved race and ethnicity into tory or inadequate care must be avoided, because the forefront as important variables in the dis- the presence of bias leads to moral and legal course on health outcomes for Americans. These imperatives. variables symbolized conspicuous inconsisten- Nonclinical factors such as race may not consis- cies in the quality of health services that differed tently demonstrate the presence of bias. by ethnic group for people living in the United Socioeconomic status, for example, as an influence 4 Providing Medical Care to Diverse Populations 57 on decision-making, may also result in debatable of interethnic encounters in which prejudice is recommendation for treatment [4, 5]. Diagnostic called into question. Cognitive dissonance failures linked to errors in judgment can stem from describes the mental reframing of a given situa- automatic thinking compared to a more consciously tion that decreases the level of discomfort that critical or analytic approach [6]. Stereotypes are a might warn of the presence or employment of form of automatic thinking leading to assumptions objectionable reactions. Rationalizations and jus- and a faulty foundation for action. tifications are utilized. These protective systems of self-esteem allow for differing perspectives on Intersectionality communication and behavioral missteps that Most definitions of diversity include a broad- breach effective patient engagement in a cross- based description of the concept taking into con- cultural encounter. sideration that different dimensions of social location are not mutually exclusive in understanding impact. Race, gender, and age, for Cultural Sensitivity and Clinical example, are interconnected aspects of selfhood. Practice These interdependent characteristics influence personal encounters, and their state of co-occur- In a 2004 position paper, the American College rence is known as intersectionality: of Physicians encouraged provider awareness of Intersectionality is a way of understanding and personal bias and stereotypes as an important analyzing complexity in the world, in people, and in course of action needed to understand the degree human experiences. The events and conditions of to which these factors could influence healthcare social and political life and the self can seldom be decisions. As a case in point, DelVecchio et al. understood as shaped by one factor. They are shaped [9] described the so-called medical gaze that by many factors in diverse and mutually results from professional training. This expres- influencing sion suggests the manner in which the clinician ways. When it comes to social inequality, people’s organizes information that pertains to a specific lives and the organization of power in a given society are patient. better understood as being shaped not by a single Of course, no clinician can be an expert on axis of social division, be it race or gender or class, every culture of varied patients they treat. Every but clinician, however, can gain insight and a degree by many axes that work together and influence each other [7]. of expertise about the culture of each patient by following a few simple guidelines. Intersectionality brings a more holistic view to First, culture needs to be defined. Even though understanding the dimensions of othering [8]. the dictionary gives several definitions of culture, The importance of the construct to a healthcare the ones relevant to this chapter include (a) the paradigm embraces the idea that response to beliefs, customs, practices, and social behavior of some aspect of identity based on flawed percep- a particular nation or group of people; (b) a group tions has import for the patient experience of of people whose shared beliefs and practices care. The middle class, boomer, male, heterosex- identify the particular place, class, or time to ual, White provider may have a stressed encoun- which they belong; and (c) a particular set of atti- ter with a homeless, Black, transgender, tudes that characterizes a group of people. Simply millennial. stated, culture describes the beliefs, behaviors, and values held collectively within a group, orga- Cognitive Dissonance nization, region, or nation. Cognitive dissonance may provide insight into Including the information about a patient’s the lack of awareness that allows for discrimina- cultural background makes sense in contempo- tory behavior. Red flags typically do not go up rary clinical practice for several reasons. Clinical when socially undesirable reactions become part decisions must have exacting quality and bear 58 D. Washington and R. Doyle scrutiny. High decision quality is an important much of his younger years living primarily with goal and the ultimate example of good patient his White mother and grandmother. Even more care [10]. Applying this information in a practical pointedly, how similar was his boyhood in Hawaii and workable way is a worthy goal. The process to that of an African American boy growing up in of making a decision is a particular example of Harlem? How was his experience at Harvard information utilization, and illustrative mental University like that of a young Black man attend- models of population groups can be effective aids ing Howard University? From the model of in care delivery. These cognitive models can be African American as a generic cultural designa- complex in design and result from processing tion, in what manner is any of this a pertinent extensive information—what is seen, read, and context for the aspiring culturally sensitive clini- experienced must be accurately applied for effec- cian? How might any of this contribute to under- tive care of the individual. standing the person receiving medical care or On an individual level, each patient presents treatment? as a product of several cultures, and each of these cultures influences the individual’s beliefs about the way the world works and the way people Teaching Implications of Race should interact. Various cultural imprints deter- and Ethnicity mine a patient’s behaviors, including social gestures, use of eye contact, facial expressions, Race and ethnicity have gained attention as manner of dress, and rituals for greeting. The important to understanding healthcare quality; patient’s values, such as the importance of family more specifically, the influence of these factors life, career, religion, and social responsibility, all on defining excellence in patient care is increas- derive from some interplay of cultures in that ingly apparent. The significance of ethnic iden- individual’s life trajectory. tity to assessment, care, and discharge planning As this textbook goes to press, Barack Obama are evident, and these domains of practice hold is serving his second term as president. Divested implication for the clinician-patient relationship of his role as leader of the country and using him as a function of clinical decision-making. as a model of a cultural being, how would a clini- Knowledge of the group as it relates to those who cian meet the challenge of incorporating Mr. are culturally different often supersedes the cus- Obama’s well-known cultural background into tomary value for the uniqueness of each an understanding of who he is as a person? This individual. is a complicated question from a clinical perspec- The movement to describe and educate tive. The president self-identifies as African healthcare providers about cultural sensitivity American; however, this over simplifies his rich and its inclusion in individual practice brings cultural heritage. African American may fit the into closer range the issues raised by health dis- president better than most that choose this cul- parities. Culturally competent care, cultural sen- tural identity given his father is of African heri- sitivity, and culturally and linguistically tage and his mother was born in America. For the appropriate care are examples of terminology majority of African Americans, many generations that indicate a change in medical and nursing separate them from the nearest relative of African perspectives on health management and educa- ancestry. On the other hand, Mr. Obama knew his tion. This nomenclature is comparative, and it father’s precise birthplace and the customs and orients clinical practice and principles of care to religion of his relatives. Many of his close rela- the unique end users of health services accord- tives, including a half brother, still live in Africa. ing to the cultural identity of patients, their fam- The actual impact on personal identity and world- ilies, and the communities in which they live. view of this cultural connection as it compares to The consumer becomes the focus of the health- other African Americans is an interesting point care experience within this paradigm, while the for discussion. For example, Mr. Obama spent resulting notion of equal treatment underscores 4 Providing Medical Care to Diverse Populations 59 the importance of consistency in action, inten- The authors have created a series of rhetorical tion, and effect as essential qualities of good questions to help clinicians reflect on their own clinical practice. To a notable extent, such care diversity. See Exercise 1 below: is assumed impervious to inexplicable variation. For example, a Black physician, who attended Exercise 1 Harvard Medical School, might find less com- What is your cultural identity? mon cultural ground with President Obama than What is your race? Is this how you self- might be assumed. Ethnicity as a basis for short identify most of the time? cuts to understanding others can cause problems What is your gender? Is this also your gender in the clinical relationship. On the other hand, expression? becoming a cultural anthropologist for each What is your religion or spiritual tradition? patient from a different cultural background is What is your ethnic heritage? In what way are untenable. Clinical tools are needed to gather you connected with its customs, beliefs, values? information important to the context of care that What is your sexual orientation? What is the is intended using the concept of cultural sensi- impact of culture/ethnic identity? tivity. Such tools are nuanced with the social What is your socioeconomic status? Is it based history of cultural groups. in family support or autonomous living? Rawls [11] explored the difference between What is your political point of view and how Black and White conversational codes of con- is it informed by any aspect of your identity? duct. In a social environment, initial ingroup The longer the list of questions, the more conversational encounters are managed differ- obvious cultural diversity becomes. A self- ently: for Whites, introductory dialogue is examination based on this interview tool provides focused on information gathering, and social an awareness of personal identity. Most clini- credentials (occupation, place of residence, edu- cians have never taken the time to think about the cation) are established at the beginning; for nuances of their own cultural diversity, so one Blacks, introductory talk separates into what is would not be surprised that the average clinician judged public or private in addition to nonhier- likely knows even less about the patient’s cultural archical communication as the basis for rela- complexities. Once a comprehensive understand- tionship. Information itself is important to ing and appreciation of the patient’s cultural Whites, “White Americans prefer to build their background is established, the clinician can side- conversations only after the production of cate- step suppositions or stereotypes based on a single gories” (p. 249). When the aforementioned pro- aspect of identity. cesses do not occur, making sense of the The term cultural diversity extends the notion interactions becomes problematic, and from a to encompass ethnic variety, as well as socioeco- Black perspective, category questions require nomic and gender variety, in a group, society, or motive, i.e., the social history of the group cre- institution. Although ethnic, socioeconomic, and ates guardedness. Caution is culturally prudent gender variety cover some of the cultural diver- as it relates to type and amount of information sity encountered in patient populations, cultural shared. diversity manifests in many other forms. An example of wariness relevant to healthcare In Patient Care Services at Massachusetts is the quality and effectiveness of the contempo- General Hospital (MGH), there are seven pillars rary clinical interview. The current interest in cul- that define the populations of interest covered tural sensitivity aids in understanding why by a curriculum on cultural sensitivity and African Americans are circumspect in their diversity. These are race/ethnicity, age, gender, answers to certain questions. This tendency is rel- socioeconomic status, sexual orientation, reli- evant because clinical outcomes are dependent gion/spirituality, and physical/cognitive ability. on analytic data as well as the best discretionary These population groups have a social history information collected from the patient. that locates their position as the marginalized or 60 D. Washington and R. Doyle vulnerable in the terminology used in the dis- the individual practitioner moves new questions course on unequal treatment and disparities. to the forefront of healthcare and disparities Consider that an ethnic minority patient may research. If scientific inquiry is to be thorough, view her or his cultural background differently there is an unavoidable question in the search for than may be assumed by a nonminority clini- answers to health disparities. What if differential cian. For instance, Dr. Jones learns that his new treatment is the result of ethnic bias by the health- patient, Jian X., grew up in China. He assumes care provider? that she prefers traditional Chinese medicine interventions and refers her to the new Alternative Therapies Clinic for acupuncture to Ethnic Bias in Clinical treat her carpal tunnel syndrome. Dr. Jones feels Decision-Making a sense of satisfaction with the referral to a new hospital service established to support and serve In answer to the concern about a level of compe- a diverse population. Jian, however, is disap- tence in clinical practice as well as quality and pointed that Dr. Jones did not simply prescribe a safety in care delivery to the increasing domi- pill to relieve the pain and inflammation. In nance of a multicultural society in the United China, questioning a doctor’s authority equates States, a course of action to address these issues to disrespect, therefore Jian does not consider became a part of the national healthcare debate. asking for an alternative to the prescribed ther- In 2004, the Agency for Healthcare Research apy. If he knew Jian better, Dr. Jones would and Quality (AHRQ) and the Office of Minority have understood that Jian identifies herself first Health (OMH) established a research agenda to as an engineer, second as a woman, and third as identify the components of cultural competence. a Chinese immigrant. As a structural engineer, From an organizational perspective, the effec- she makes decisions based on math and science. tiveness of this approach began to appear in the Jian would have welcomed a discussion about literature Betancourt et al. [12]. Nursing models the evidenced-based advantages of one anti- that captured concepts such as expertise, skill inflammatory medication over another, but she development, knowledge, and awareness gained reticently accepted the treatment Dr. Jones pre- attention Campinha-Bacote [13]. Such efforts scribed based on his well-intentioned assump- addressed issues of mixed performance in health tion about her. Her firm relies on Jian to meet a outcomes evidenced in the literature comparing deadline on a major project, so she needs relief population groups, and it has been possible to as quickly as possible. Her dilemma includes audit research and produce studies demonstrating scheduling an appointment with acupuncturist care below par based on ethnic background. in 3 days or taking a prescription that might However, there is not enough complied evidence offer relief in a matter of minutes or hours. The to give legitimacy to the claim of ethnic bias in cultural context for Jian’s problem illustrates clinical decision-making such that the process the need for clinicians like Dr. Jones to take a can objectively test positive for its presence. culturally sensitive approach based on actually Figure 4.1 is a conceptual model of proposed understanding the patient’s needs rather than influences on clinical decision-making as it assuming they do. relates to unfamiliar ethnic minority culture. It is Clinicians are more likely to approach the a conceptualization by the authors of the decision challenges of care for a multiethnic and multilin- maker who does not choose the prevailing treat- gual population more effectively, if cultural ment for an ethnic minority patient. Although the knowledge and resources commensurate with choice may remain clinically defensible, the needs are available to them. These newly identi- alternative may not hold the same standing as the fied demands of good care require updated more prevalent treatment option. In such a sce- responses. Knowledge reflecting the domains of nario, the cognitive construct of the patient held perception, memory, and judgment endemic to by the decision maker is open to interpretation. 4 Providing Medical Care to Diverse Populations 61

Cognitive Construct Prevailing treatment choice made in clinical situation involving nonminority patient

Alternative treatment choice made in same clinical situation but involves an ethnic minority patient.

Ambiguity in mental model of ethnic group as factor in a clinical situation

Fig. 4.1 Treatment dichotomy: cognitive construct for treatment decisions involving the ethnic minority patient

Identity Theory for such familiar generalizations about social groups. These abstract properties are well known, Identification is the idea that persons perceive but conspicuously undesirable as descriptors, themselves as having a social as well as a per- because using them served to marginalize. sonal identity. Social identity connects the indi- African Americans, for instance, have a unique vidual with those considered “the same.” The American history in relation to social inequities, identity (social or individual) that dominates is but despite a context of racism and discrimina- situational, however, and theory suggests social tion, Black people forged a cogent cultural and comparison as a third aspect of the dynamic group identity. Within the characteristics of this superimposed on the dyad of identity concepts. distinctiveness, a fuller understanding of the rela- This specific instance incorporates the perspec- tionship between cultural coherence, health sta- tive that each individual also seeks an evaluation tus, and clinical decision-making may emerge. of self in comparison to those who are similar. By what means ethnic or cultural identity func- Social identity theory dates from 1979 as tions, as a factor in healthcare decisions, remains developed by social psychologist Tajfel, who unexplained. studied intergroup relations. Theoretical concepts The theoretical tenets of social identity theory included the interaction between personal iden- and related scholarly perspectives on the princi- tity and social identity Brown and Capozza [14]. ples of group membership do not nullify the con- Tajfel suggested that group assignment creates a cept of a self-determining personal identity. situation in which individuals construct a positive While individual perceptions and feelings can be sense of self, based on group inclusion. An affected by the ideas and opinions of others, it ingroup and out-group awareness is associated can also be assumed that each person within the with embracing a group identity constructed group remains an autonomous thinker. This from characteristics considered common among premise suggests the elements of a stereotype those who comprise the group. It is unclear if may be pliable to personal frames of reference in these attributes are generally viewed as diagnos- addition to models disseminated by the dominant tic of group membership or merely symbolic. social group. A group trait idiosyncratic to a shared identity The fluidity between the dominance of social is a complex construct. It is a difficult supposition identity or personal identity is a question of situ- to ascertain among large numbers of disparate ational demands. There is the implication that individuals. Nevertheless, popular culture allows trait consistent factors exist, and together consti- 62 D. Washington and R. Doyle tute identity categories. It is conceivable within Communication: Reading Between the context of this reasoning that the individual the Lines incorporation of a category means enfolding styl- ized traits that are consistent and recognizable to Let us look at each facet of culturally competent the individual member of a group, the associated communications in the medical encounter as principal group, and to the general social order. described by Teal and Street. First, the clinician must possess a communication repertoire. The Exercise 2 clinician’s communication repertoire multiplies Consider your responses to Exercise 1 then rank the effectiveness of sensitive interaction between them in the order that you feel best describes your the caregiver and the patient. According to core identity. Jian ranked her profession as the Shapiro, a culturally competent communication most important part of her identity followed by repertoire includes basic attitudes of empathy, her gender then her immigrant status. Which caring, and respect that form the foundation of all aspect of personal identity holds priority in your clinical encounters [21–24]. Fundamental com- self-concept? Which part of your individual cul- munication skills build upon active listening, tural identity comes in second, third, and so forth? acknowledging sociocultural aspects of illness, Did some aspects of your unique cultural identity inviting patient perspectives, inquiring about seem more difficult to rank than others? What socioeconomic implications of treatment, and aspect of your cultural fingerprint drives your empowering patients to make decisions [25–27]. decision process? Patients may make medical The goal of effective communication in any clini- decisions based on their unique cultural priorities, cal encounter is twofold: obtaining accurate so we as clinicians should be mindful of this. information from the patient and providing the Teal and Street have proposed four elements for pertinent information that the patient needs to culturally competent communication in the medi- make decisions about treatment. cal encounter [15]. They list communication rep- Learning tradition dictates that initial clinical ertoire, situational awareness, adaptability, and evaluations are organized in a standard format knowledge about core cultural issues [15]. starting with a chief complaint then moving to Betancourt and colleagues noted that cultural dif- the history of present illness followed by medical ferences between physician and patient may place history, family history, and social history. Those barriers to effective communication, which trans- who work with children and adolescents place lates to patient dissatisfaction, poor adherence to special emphasis on a developmental history. All treatment plans, and adverse health outcomes [16]. clinicians, however, should consider including a Others point to improved health outcomes with cultural history in every initial evaluation. Some patient-centered communication [17, 18]. clinicians delegate the cultural information about Moreover, a culturally sensitive clinician should the patient to the social history, and this usually be able to realize and respond to the sociocultural suffices, if the patient comes from a similar cul- differences between physician and patient [19]. tural background as the clinician. However, add- While patient-centered care provides for improved ing a separate cultural history for any patient care for all individual patients, culturally compe- coming from a different background than the cli- tent care emphasizes appropriate and equitable nician, or one not represented by mainstream cul- distribution of care in patients from diverse and ture, is beneficial. The cultural history serves as a disadvantaged backgrounds [20]. We posit that valuable source of information for anyone who patient-centered care enhances culturally sensitive reads the patient’s chart. Moreover, this type of care and lies at its core. Without a patient-centered documentation should be viewed as a process approach, those patients who present from outside instead of simply part of the initial evaluation. the mainstream parts of our society will feel mar- Think of a cultural history as an evolving pro- ginalized and likely not return to treatment unless cess. It begins with the initial evaluation and con- emergency situations force them to come back. tinues to grow with each subsequent encounter. 4 Providing Medical Care to Diverse Populations 63

Of course, the clinician-patient relationship will Sometimes subtle, such behavioral changes usu- need nurturing. Sometimes, a gradual accumula- ally signal a problem or misunderstanding in the tion of cultural information is the most effective patient-clinician relationship. The patient may and efficient approach to gather information. perceive race base cues from the clinician during Consider the case of Mr. M., a Mexican migrant the encounter. Maintaining self-awareness related fruit picker in California’s central valley. His to bias, prejudice, micro-aggressions, and cul- “green card” expired several months ago, but his tural miscues can influence body language and poor English prevented him from finding the interpersonal reactions that can derail the clinical appropriate authorities to renew his worker visa encounter. According to Epstein and Street, situ- status. Unfortunately, Mr. M. found himself in ational and self-awareness enhance communica- the emergency room after he accidentally gashed tion to clear up confusion, deal with his left hand due to a slip of the pruning knife. As disagreements, and come to a common under- the young resident tried to establish rapport by standing of the medical problem and the pre- learning about the patient’s cultural background ferred treatment options [17]. Situational and through the use of an interpreter, Mr. M. became self-awareness result from “mindfulness” in the visibly anxious. The resident persevered with fur- medical encounter. The term “mindfulness” ther questions, such as: How long have you been refers to a new form of psychotherapy based on in the United States? Where did you live in cognitive behavioral therapy that draws upon Mexico? Do you have other family members liv- Eastern meditative techniques [28, 29]. In ing with you here? The resident intended for the essence, mindfulness allows the clinician to fully questions to establish a connection and rapport, focus on the patient in the present moment. but they worked in the opposite direction. Mr. M. Conversely, the role of race-ethnicity in a feared that the clinician wanted this information mental model is provocative. As a social con- to pass it along to the immigration authorities. struct, its connotation is not typically positive. After the resident finished suturing the wound Placing race-ethnicity in the data set of infor- and giving Mr. M. instructions for after-care, she mation available to a decision maker is nettle- asked him to return in a week for suture removal. some since it evokes unsettling historical Mr. M. smiled and nervously thanked her. He, matters and causes doubt and uncertainty about however, dared not return to the hospital, since he contemporary ones. It is also difficult to con- thought immigration officials would be waiting cede that in any given situation, race-ethnicity to deport him. is insensible to another. To say the concept does In retrospect, the resident could have chosen not register negatively is not to say it has no less threatening questions or simply deferred register. The manner in which it correlates as these types of questions until she gained his trust. data in a decision schema is presently unde- She did not know about her patient’s visa status, fined; consequently, the probability that the and that can be forgiven. However, she missed the concept indicates a point of uncertainty or escalating anxiety Mr. M. exhibited and she did ambiguity in the decision process by its simple not adjust her approach. Teal and Street refer to existence is worthy of consideration. If the this ability to perceive and attend to the nuances in race-ethnicity construct is included as a vari- the patient’s behavior as situational awareness. able, it is a reasonable expectation that its use is credible. In other words, it is important to understand whether race-ethnicity indicates a Awareness: Keeping an Eye narrowly defined group, or whether it more on the Compass appropriately serves as a parenthetical determining factor within the context of other issues. Situational awareness along with self-awareness Stereotypes associated with race-ethnicity are comprises the second of the four critical elements sometimes a proxy for a combination of quali- in culturally competent communication [15]. ties belonging to a person. On the other hand, it 64 D. Washington and R. Doyle may be imposed on characteristics outside per- Ethnocentrism sonality. More specifically, is race-ethnicity irreducible and not able to be further divided or Ethnocentrism—or the perspective that the cul- simplified into component parts? ture of the ingroup is the definition of normal— In mindfulness groups, one of the more serves as the boundary marker for a group that memorable exercises involves eating a piece of dominates. For example, historically European chocolate. Each member of the group receives a and biomedical are labels for what is familiar and single candy as a group leader guides the par- approved in the operating standards accepted by ticipants through a full appreciation of that one the American healthcare system. This is espe- piece of chocolate. The leader instructs the cially true in meeting the requirements of the group to savor the aroma then relish the texture marketplace (e.g., care costs, funded research) as and color. Over the course of several minutes, an influence on care delivery. However, this group members experience every detail of the viewpoint may have run its course with the latest small treat before they taste it. Most people have census, because the dominant group has reached never focused on a piece of chocolate so a tipping point with the mass arrival of non-Euro- intensely, so they never fully appreciated the pean populations [30]. Ethnocentrism was once essence of chocolate. Unfortunately, the time- the prototypical model of care delivery, since the pressures of managed care rarely allow clini- demographics of the United States reflected the cians to savor complex cultural diversity that European roots of the nation. What holds the each patient brings to the encounter. Physicians attention is the international sources of these new and other practitioners rush to obtain diagnostic demographics flow from countries customarily information with the goal of a quick and effi- treated as lacking in global value or importance cient move to treatment. Like someone who (e.g., third world countries, war torn countries, mindlessly gobbles a piece of chocolate barely developing countries). Upon residence in the tasting or enjoying the experience, clinicians United States, census designations force adop- miss out on the cultural flavors that make clini- tion of checklist identities culturally informed by cal encounters so rich. The pressures of acuity the American experience. More specifically, and third party payers drive interactions to the African becomes Black and Mexican becomes contemporary care environment. Hispanic, and the consequence of this is that dif- Imagine, instead, a mindfulness approach to ferent immigrant groups now dominate commu- each patient encounter. In this scenario, each nities that are the focus of a contemporary public clinician becomes a discerning expert on health agenda. In Massachusetts, for example, patients from very diverse background. Once the gain in state population for the last census she or he adopts the mindfulness mindset, that was dependent on immigration. New immigrants clinician can appreciate the unique ways that a arrived to the state from South and Central person’s race, religion, ethnic background, sex- America, India, China, Russia, Vietnam, and the ual orientation, gender and/or age, come Caribbean [31]. Ethnicity and health disparities together as the richly textured cultural identity are two typically correlated variables. of a patient. The interface between race, reli- The characteristics associated with ethnic gion, ethnic origin, sexual orientation, gender, identity have the potential to inform a more com- age, and a number of other elements produce prehensive understanding of a group’s social cultural identity as it is currently understood. identity. The latter involves the larger concepts of The patient and the clinician may not be cultur- categorization (Black, Muslim, southerner), ally congruent, but this offers opportunity for identification (ingroup, out-group), and social the professional and personal growth, espe- comparison. Ethnic identity with its cluster of cially for clinicians who wish to understand the descriptive features (race, religion, language, his- variety of human experience that diversity tory, etc.) has the capacity to more precisely out- offers. line the features that constitute a social identity. 4 Providing Medical Care to Diverse Populations 65

Once the link between social identity and ethnic of perpetual foreignness of some populations is a identity has been established, it becomes possible source of resentment that targets immigrants as to explore the interpersonal and intergroup rela- largely illegal, poor, and heavy consumers of tax tionships that are often problematic in the clinical dollars. Such stereotypes of ethnic groups may setting. contribute to unequal treatment in care. Ethnocentrism is often cited as an example of Ethnocentrism was once the prototypical model an ingroup perspective [32], and attached to these of care delivery as mentioned earlier. categories are value judgments [33], because the Today, technology allows for small or remote ingroup designation creates boundaries and con- facilities to connect with interpreter services via scious articulation of differences motivated by electronic audio or audiovisual conferencing comparisons. The anticipated outcome from such devices. An interpreter often provides cultural processes is a positive sense of self-worth stem- insights. Nevertheless, specific skills are needed ming from group inclusion. The notion that social to work effectively with this valuable resource. identity is created by its designate and adopted For example, the clinician should observe the freely by them is incorrect, since it mistakes patient while the interpreter asks questions in the social identity for group identity. Prejudice and patient’s native language or receives information stereotypes by the social identity designators in the other language. It is instinctive to look at make this proposition questionable. To the con- the person speaking, i.e., the interpreter; how- trary, these negative influences are often the ever, the focus of an interpreter-facilitated clini- impetus to disestablish a social identity and when cal interaction remains connecting with the the creation of a group-based identity is the outpatient and not the interpreter. Attention to the growth of a circumscribed social existence the patient allows for observation of the patient reac- results demonstrate a high degree of refinement tion to questions and any discomfort associated [34, 35]. This cultivation is typically given dis- with the answers. A mindfulness approach proportionate meaning outside the social struc- applies in this case even with major language bar- ture of the relevant group. An emblematic riers between the clinician and patient. illustration is the way African American frank- At other times, an accent, medical jargon, or ness is misconstrued. Outside its cultural para- idiomatic expression can lead to misunderstand- digm, it may seem to be brusque or socially ings. The clinician must observe the patient closely incorrect behavior. to discern whether any change in body language or facial expression signals a problem. Using situational awareness and self-awareness permits clini- Negative Social Frames cians to remain mindful in the moment with their patients and prevents miscommunication in shar- The difference between the patient’s and the clini- ing information and arriving at an appropriate cian’s cultural identities can lead to inaccuracies treatment plan acceptable to the patient. in communication. Sometimes a language barrier In a mindfulness-based patient encounter, the exists between the patient and the clinician. clinician must pay attention to her/his own cultural Interpreters can be invaluable in such situations. A identity and beliefs while realizing the stereotypes contemporary subtext to this focus is the issue of and prejudices she or he might hold about persons citizenship. Since the 1970s there has been a from the patient’s demographic group [29]. This, decrease in European immigration to the United however, comprises only a fraction of the equa- States. An increase in the numbers of people com- tion: self-awareness. A mindfulness-oriented clini- ing into the country from Latin America and Asia cian also must assess the patient’s spoken and replaced this reduction. This new influx of people unspoken reactions to her or his behaviors: situa- created concern in the native-born population tional awareness. The patient’s reactions may about the potential loss of a core American iden- manifest as changes in facial expressions, shift in tity Grant Makers Health [36]. A perceived state posture, choice of words, tone of voice, or even an 66 D. Washington and R. Doyle awkward silence. Although this sounds like sound the clinical encounter, it is reasonable to surmise a advice for any patient interaction, clinicians should type of relationship not subject to control of the show particular vigilance for these signals when- will. In the contemporary healthcare system, it is ever they meet with patients from cultures quite becoming less and less likely that patient and pro- different from their own. vider have more than a sporadic and incidental Discomfort with ethnic bias as a factor in clin- relationship, and they are very often not known to ical decision-making is related to uncertainty one another. Expanding the premise further about the existence of the antipathy usually asso- includes acknowledgment that development of ciated with race prejudice (Hobson 2001) [37]. expertise is based on accumulated knowledge of Inveterate dislike as opposed to a random, nega- the typical patient. This emblematic patient tive reaction based on a real time event chal- becomes a point of comparison and is affectively lenges the traditional image of the egalitarian and representative for each clinician of what is reason- objective clinician. This latter depiction is the able or excessive, characteristic or embellished. more customary portrayal of the health profes- The emotional reaction of the Hobson [37] study sional and is not usually part of public dispute. (Hobson 2001) subjects and their responding Nevertheless, the experience of African behavior poses an interesting scenario of stimulus Americans with the healthcare system is some- and response between patient and provider. In times pictured differently. A 1999 special report particular, Rosenthal [38] posits that when the supported by Seattle Public Health explored the provider is interacting with an out-group member experience of 51 African American patients stereotypically viewed as “loud, hostile, lazy, through an interview project. Those questioned criminal and low intelligence” (p. 132). related incidents in which they described differ- Rosenthal [38] either as the one patient of the ential treatment, and many occurrences included day or the tenth from the specified ethnic group, the a “perceived negative attitude” from healthcare effect on care deserves inquiry. With feelings as professionals further detailed as behavior that context for the clinical encounter, there is sound was “rude,” “cold,” “inattentive,” and “belittling.” basis to surmise the possibility of a strained and “The perceived negative attitude exhibited by unacknowledged tension in a cross-cultural interac- health care providers or their staff members were tion. While it may be true that not all clinical not reported as hostile but as uncaring or rude encounters involve the activation of ethnic bias, the behavior” (p. ix). The respondents were patients resulting hypothesis exploring the kinds of data that from approximately 30 different health centers increase or decrease the presence of bias, prejudice and recalled experiences as early as 10 months and discrimination in thought and practice becomes previous to the interview. Types of perceived dis- a worthy goal. Rosenthal [38] goes further crimination captured by the report were: differen- “Research can shed light on the way racial biases tial treatment, perceived negative attitude, treated are activated and how they persist, fostering the as dumb, made to wait, ignored, pain ignored, development of empirically validated strategies to inflicted unnecessary pain, racial slur, harassed, neutralize the effects of these stereotypes” (p. 139). being watched, and health personnel exhibited Bodenhausen et al. [39] did the work of inves- fear (Hobson 2001) [37]. tigating the influence of affect on perception and While the Hobson study outlined examples of behavior between ingroup and out-group mem- behaviors identified as discriminatory by the bers. In their writing, the authors acknowledge respondents, it was not the purpose of the study to “psychologists have known that, through experi- examine another unexplored phenomenon within ence, certain stimuli come to elicit consistent its chosen scenario. More specifically, the affective reactions” (p. 321). The barrage of responding behavior from the study subjects to social messages about ethnic groups has not the actions and manner of the clinicians was not abated with the passage of time, and in the part of the inquiry, so the interplay between absence of censure, the amount of such informa- patient and provider is raw material for further tion absorbed by any individual is open to conjec- research. With reciprocal feelings as context for ture. Whenever there is no social contact to 4 Providing Medical Care to Diverse Populations 67 contravene about the information communicated, assessment of this account from the patient is the the patient becomes an avatar of those socially responsibility of the nurse and doctor. The conse- embedded messages. Bodenhausen et al. quence to this within the set of circumstances that observed that the amount of research scrutinizing constitute a cross-cultural interaction is the piv- the characteristics that explain affect concomi- otal point of the following research. tant with stereotypes is insufficient. The contemporary environment for clinical The experience of any clinician with social dif- practice is fast paced and technologically sophisti- ference may be limited. It is not unusual for the cated. A diverse patient population with multifac- work environment to be the primary contact for eted needs make care delivery intricate and often significant interactions between cultural groups. pressured. The discourse on economics of care Awareness of this paradox informs the chosen presently joins the prevailing business case for care method for engaging clinicians in a learning expe- in the form of quality, safety, and evidence-based rience with diversity. In Patient Care Services at practice. Regulations and the debate for better- MGH learning experiences are experiential and managed resources make the element of time an interactive. The use of games, case studies, pro- important factor that helps determine practice char- files of local communities and neighborhoods as acteristics. The 20-min patient visit is a standard well as educational offerings on topical events are constraint on present-day practice, and as previ- a few approaches to making diversity “come to ously mentioned, short time frames facilitate the life” for staff and employees. automatic processes involved with stereotype activation. This conceptual model of the healthcare environment represents the cross-cultural encoun- Healthcare Environment ter and the environment that influences it (Fig. 4.2). and Diversity Sometimes the patient might not appear so different from clinician; however, situation Part of the decision-making process in healthcare awareness makes subtle difference more obvious. is to gauge the seriousness of signs and symp- For example, Sally Hendricks, NP felt something toms as a subjective report from the patient and was wrong as she handed her patient a prescrip- the clinical distress they cause. An objective tion for the newest antidepressant medication to

Conceptual Model of ethnic bias in clinical decision-making

Patient-provider interaction and area of interethnic ambiguity Provider’s cognitive schema For decision-making

Patient presents clinically within ethnic identity

Health Care Environment • Time • Task Pressure

Fig. 4.2 Conceptual model of ethnic bias in clinical decision-making 68 D. Washington and R. Doyle hit the market. Calvin W, a 37-year-old restaurant and a cultural misunderstanding is in the making. owner, took a deep breath as he took the prescrip- Subtle signals, such as the ones above, indicate tion, folded it, and slipped it into his pocket with- that a cultural bias might be impairing the inter- out looking at it. His raised eyebrow indicated action, which leads to major implications for that something bothered him, but the nurse prac- effective treatment. titioner could not identify the problem. He told Aside from economic disparities, the National her that he knew he had depression and his symp- Healthcare Report from the AHRQ from 2011 toms fully met the criteria for major depression, indicated that Blacks and Hispanics with major so the diagnosis was not the issue. The side effect depression were less likely to receive treatment profile of this new medication offered substantial during the 12-month observation period com- efficacy with few side effects; therefore, fear of pared to Whites [40]. In addition, the report noted untoward reactions did not explain his reaction. that Black adolescents and adults received treat- Calvin W appeared to be middle class based on ment for alcohol and substance abuse problems his attire and manners, so Sally did not suspect more frequently than their White and native that he experienced a great deal of financial strain American counterparts [40]. Perhaps clinicians since the recession of 2008. Mr. W. happens to be make stereotypic assumptions about certain struggling to keep his restaurant open and, at the racial or ethnic groups, and this translates into same time, pay child support. Perhaps the stress disparities in healthcare delivery. Such disparities of being a single man with responsibilities to his might be avoided if clinicians challenged their family and employees contributed to his depres- biases through self-awareness in the doctor sion; nonetheless, Sally did not realize he could patient encounter. Thus, situational and self- not afford to pay for the prescription, which awareness serve as the second part of the cultur- meant that he would not start treatment. Sadly, ally competent care equation. However, the nurse practitioner missed the socioeconomic self-awareness plus situational awareness does issues that often become the proverbial “elephant not necessarily equal culturally sensitive medical in the room.” She assumed that he shared her care. middle class security. According to the US Census of 2010, about 20% of the non-elderly population are uninsured Adapting: Changing Course [40]. Interestingly, of the uninsured, 46% are in the Encounter White, 31% are Hispanic, 16% are Black, and 5% are Asian American [40]. Today, more and Another part of the equation involves adaptabil- more people are slipping from one socioeco- ity. Of course, perceived similarities between nomic class to a lower one, which causes embar- physician and patient can enhance the dynamic rassment and a great deal of difficulty adjusting relationship; however, patients within any cul- for that person and/or family. Moreover, a self- tural group show a wide range of individual vari- employed middle class person might not be able ability [41]. Additionally, clinicians today to afford insurance that provides the basic cover- frequently encounter patients from cultures and age a person on welfare receives for free. Cultural backgrounds quite different from their own. In differences are often obvious, but not always. either case the physician/clinician/researcher Calvin W came from a middle class White neigh- must adapt their approach to accommodate the borhood like Sally, but circumstances caused him sociocultural health beliefs of such varied patients to slip down the socioeconomic ladder recently. [15]. Of note, patients who actively participate in Some patients feel uncomfortable talking about medical visits tend to receive more responsive certain subjects, such as economic problems, care from their physicians [42]. Patients become sexual practices, and the like; nevertheless, clini- more active in treatment whenever the physician cians may need to rely on situational awareness offers more facilitative interactions [15]. to recognize clues that something might be amiss Physicians facilitate interactions with their 4 Providing Medical Care to Diverse Populations 69 patients by taking a reflective demeanor that Of course, he hit the mark, and Mrs. L. started adjusts to the patients cultural and personal to explain her dismay of finding fresh ingredients beliefs while in the therapeutic moment of the for her cooking. Dr. Nguyen secured her trust appointment [15]. Although Schon suggests that without stepping into the quagmire of politics such reflection and the subsequent adaptation to that likely caused Mrs. L. to act in a guarded and the situation should happen during the encounter, suspicious way with him at first. At that point, the sometimes a reflection after the fact reveals review of systems and other medical information aspects of situational and self-awareness that gathering flowed smoothly. Dr. Nguyen main- slipped past the physician during the busy visit tained situational and self-awareness and then [15, 43]. Adaptability integrates awareness with adapted his approach to meet Mrs. L. on a human- action. level sharing pleasures and disappointment. This Consider Dr. Nguyen’s dilemma: Mrs. L. is a allowed Mrs. L. to relate to Dr. Nguyen as per- 63-year-old Hmong widow, who presented to son, not someone possibly from another political the Ambulatory Care Clinic for the treatment of party that persecuted her people after America a possible urinary tract infection. The recep- withdrew troop from Vietnam. tionist intentionally put Mrs. L. into Dr. Nguyen’s schedule, because the initial screening information indicated that the patient emi- Core Knowledge: Continuing grated from Vietnam, and so did Dr. Nguyen. Cultural Education Unfortunately, the receptionist did not know that Hmong people identify more with their To complete the equation, a culturally competent ethnic background than a particular country. clinicians must know about core cultural issues in Fortunately, Dr. Nguyen did. Therefore, he paid the patients they treat [15]. Carrillo and col- particular attention to the patient’s body lan- leagues suggest that clinicians should focus more guage and facial expression to maintain situa- on core cultural issues of an individual patient tional awareness while filtering his stereotypic rather than culture of the group to which the view of the Hmong people that he learned from patient belongs [44]. This prevents the clinician his older family members to incorporate self- from relying on stereotypes related to such attri- awareness into the interview. From the moment butes as race, age, gender, religion, ethnicity, or he met Mrs. L., Dr. Nguyen sensed that the socioeconomic status. The authors feel this patient seemed suspicious of him. Instead of applies not only to clinicians but also to research- jumping into a review of systems, he decided to ers and educators as well. shift and reminisce about the beauty of the Likewise, patients may identify primarily Vietnamese landscape, which was so different with one or two major features of their cultural than of East Boston. As Dr. Nguyen described background, i.e., a Chinese American man or a some of his favorite places in Vietnam, Mrs. L. Latina woman from Costa Rica. However, such slipped into a smile as she nodded in agreement stereotypes only scratch the surface. Simply while Dr. Nguyen described the lush landscape adding one layer, such as marital status, makes around the region that the patient spent her the cultural identity of these two individuals childhood. Once he saw the smile, Dr. Nguyen more complex. What if the Chinese American then switched to a sadder tone of voice as he man were married to the Costa Rica woman in mentioned that he has never been able to find the example above? Of course, the plot thickens pho, a Southeast Asian soup, that tasted as good by adding one more layer. Now, imagine that as pho he ate as a boy in rural Viet Nam. they had a boy and a girl, who were fraternal Although Dr. Nguyen knew little about the twins. How would the children identify them- Hmong culture, he expected that she shared his selves from a cultural point of view? Might the disappointment of the American version of a son identify more with his father’s Chinese heri- Southeast Asian cuisine. tage or the daughter with her mother’s? Does 70 D. Washington and R. Doyle their twin status impact their cultural identity? institutions for cultural consultation. To take full These and many more questions attest to the advantage of these resources, clinicians should complicated interactions of different cultures in think outside of their department and even their this hypothetical couple and their children. profession. For instance, John, a physical therapist, felt frustrated that Mrs. K. showed little motivation to complete the exercise program he Implications of Diversity prescribed each week. She came to live with her and Clinical Practice son in Texas after her husband passed away in Pakistan at age 80. Instead of giving up, John con- Recently, the United States and a number of other tacted Dr. Shah, an orthopedic resident from Western countries experienced major shifts in Pakistan, whom he met at a case conference demographics due to immigration patterns. 2 weeks earlier. Given that physical therapy According to Annelle Primm, M.D., M.P.H., requires a great deal of hands-on treatment, Dr. director of minority and national affairs at the Shah wondered whether the patient’s very strict American Psychiatric Association, minority births Muslim background caused her to be uncomfort- exceeded White births in 2011, and 50% of 3- and able with a man, other than her husband, holding 4-year-olds were White, while the remaining 50% her hand and touching her as John needed to do to were non-White [40]. This means that today’s help her during the session. He suggested that a majority may become tomorrow’s minority. In the female physical therapist might make her feel end, clinicians must acquire skills to manage more comfortable in the aspects of therapy that patients from cultures other than their own. For required hands-on assistance. It did. John stayed example, a Black internist identifies herself as involved with the case by giving verbal support, member of the minority, but she must understand but Mrs. K. seemed much more motivated and core cultural issues of other minorities and even comfortable with Cathy, one of the female physi- those of the majority group to facilitate a cultur- cal therapists in the group, who took over the ally sensitive medical encounter. With patients hands-on treatment. Colleagues offer a valuable from so many cultures converging in waiting resource for cultural consultations, so take advan- rooms, can anyone ever achieve enough knowl- tage of their expertise even if that person works in edge to gain true cultural sensitivity? a different department or area of your institution. Of course, assimilating knowledge about our Possibly the best, cultural resource remains patients’ core cultural issues poses certain chal- the patient. Most patients happily share informa- lenges, but technology provides part of the solution about their own culture within the context of tion. Only a few decades ago, learning about the the trusting relationship. As described earlier, customs and mores of patients from foreign suspicions about the motives of the clinician can countries or different backgrounds than clini- be problematic. Building trust in the cross-cul- cian’s own typically required a trip to the library. tural encounter becomes the foundation of a suc- Even a decade ago, the clinician would still need cessful clinical experience. Avoiding questions to find a computer to search the Internet for such that arouse concern about immigration or internal information. Now, however, such information is revenue agents is paramount. Begin the interview at hand with handheld devices, i.e., smart phones, with benign questions, such as: electronic tablets, and other devices. Another source of information comes from • What is the weather like in your hometown of colleagues. As the population grew more diverse, Caracas at this time of year? equal opportunity employment laws shifted hiring • I know that no one can cook as well as your practices. As a result, the very homogenous White mother, but do any of the restaurants in town male medical staff of the 1950s evolved to the serve Cambodian food close to the kind your spectrum of diversity we see in medicine today. mother made? This diversity provides ready resources in our • How do you say “hello” in Cantonese? 4 Providing Medical Care to Diverse Populations 71

Clinicians benefit from cultural curiosity. A ations a clinician might encounter, other question stemming from sincere interest suggests approaches to culturally sensitive healthcare a receptive and supportive provider. Additionally, delivery exist and work equally well. As described cultural diversity presents in a myriad of permu- above, a successful clinical encounter with cul- tations. Individuals who appear to be culturally turally diverse patients results from a simple similar may differ in several significant perspec- equation in which the clinician uses effective tives, e.g., economic status, sexual orientation, or communication aligned with situational and self- religion. Cultural curiosity often uncovers differ- awareness. Adaptability multiplied by a core of ences that otherwise might go unrecognized. The cultural knowledge adds to the probability of suc- trusting patient will confide and reveal as a sign cess in the cross-cultural encounter. Race, reli- of confidence in the clinician. gious beliefs, ethnic background, nationality, A number of other political and social factors gender, sexual orientation, marital status, and also play a role. Interestingly, advances in science numerous other aspects of social demographics and medicine have, in themselves, helped create give clues to cultural identity. Mental health pro- cultural diversity. For example, patients now have viders, as well as all other persons delivering access to medical procedures to transform them- healthcare services, should understand the com- selves from one gender to another. Even though plex connections between each of these clues, so hormonal and surgical procedures result in remark- that interventions that would lead to better out- able physical changes, our understanding of the comes override those that might hinder treatment psychological isolation or marginalization experi- due to a lapse in cultural sensitivity. The popula- enced by patients at various stages of the transgen- tion we treat appears so diverse, because of the der process requires much further research. amalgam of cultural traits that makes up each According to Hayes-Bautista, true cultural individual’s heritage. Moreover, each patient competence in medicine must hinge on large- constructs a hierarchy of cultural traits in which scale, rigorous, science-based approaches to one may overshadow another. For instance, is understanding the connections between culture, race more important than religious beliefs? (or behavior, and epidemiology [45]. He points to the lack of religious beliefs) The answer may be situ- Latino epidemiological paradox to make his case ational, culturally embedded, or irrelevant. [45, 46]. Latino populations show reduced risks Intersectionality is an effective framework to for the top three causes of death compared to non- bring focus to the underlying structure of informa- Hispanic Whites. The mortality rate in the Latino tion presumed to have bearing on the patient as a population is 35% lower for heart disease, 43% social being. Membership in a social group is lower for cancer, and 25% lower for strokes [47]. fluid. This variability is greatly influenced by Interestingly, these outcomes cannot be attributed interactions loaded with the baggage of object les- to high income, higher educational levels, or easy sons and representative patterns of behavior recog- access to the highest quality of healthcare [45]. nized from negative lived experiences. The issue However, careful investigation of Latino life, for the clinician is the development of skill and including diet, family structures, religious beliefs, understanding that serve as countervailing evi- and many other aspects of culture, might give dence that aspects of identity are not negative clues to this paradox that could be used to improve influences on the therapeutic encounter. Viewed as the health of non-Hispanic populations [45]. a problem domain, culturally sensitive care must point to methods and insights that produce solutions. Clinicians must demonstrate the conscious Conclusion ability to express recognition of elements of identity as data. This data is defined as pieces of infor- Although this chapter presented a paradigm for mation that function to make more specific the providing medical care to patients from different meaning of perception, perspective, and reasoning cultural backgrounds and using examples of situ- within the context of the culture-based encounter. 72 D. Washington and R. Doyle

The incorporation of the aforementioned data other hand, cultural competence connotes a level comes with a caveat. Unconscious bias may block of acumen that goes beyond what is merely ade- cognitive dissonance. Absent the necessary knowl- quate and moves practice forward to exceptional edge and exposure to diversity, it is possible for the quality and ability. While not all disciplines favor clinician to be incognizant of care compromised the concept of cultural competence over cultural by bias or prejudice. This is especially true in deci- sensitivity, skill acquisition is more aligned with sion-making that is unchecked and unchallenged. the former principle. The advancement of nurs- Clinical rounds, case presentations, and consulta- ing practice is linked to its capacity to respond to tions become critically important education tools a diverse patient population. To disregard this to develop expertise in caring for a culturally and competence would be to have nursing practice linguistically diverse patient population. This type remain in a fixed state and reducible to its past of proficiency requires a many-sided viewpoint rather than its evolving relevance to the future. and mind-set to form a therapeutic alliance. A In the end, mental health clinicians should frame of reference to approximate equivalent develop a core of cultural competence to under- meaning is part of this skill building know-how. stand patients from diverse backgrounds, but they The literature is replete with such subjects as must exercise cultural sensitivity in interacting implicit associations, cognitive load, aversive with each individual patient. No psychiatrist, racism, and unequal treatment as indirect evi- psychologist, social worker, specialized nurse, or dence of the impact that bias can have on the other mental health provider can possibly acquire quality of care provided to ethnic minorities. a knowledge base adequate to understand all the However, to solve the problem of disparities, a nuances of ethnicity, race, gender, or other ele- paradigm shift in the approach to research is nec- ment of diversity that one will encounter in clini- essary. A more vigorous multidisciplinary strat- cal practice today. Nevertheless, every clinician egy would advance the work with a renewed should be able to learn the important information sense of urgency. Dovidio et al. [48] made the specific to an individual patient so that each point that findings from social psychology and encounter with a patient evolves from a culturally the health disparities literature are not organized sensitive approach and one relevant to the situa- into an interconnected knowledge base. In like tion that caused the patient to seek treatment. manner, Drevdahl et al. [49] have offered the This chapter began with the example of same research challenge to nursing stemming President Obama. It appears apropos to end with from its focus on cultural competence as the best- a quote by President Kennedy: yet effectively unproven intervention to eliminate If we cannot end now our differences, at least we disparities. These authors have argued that in the can help make the world a safe place for diversity. discipline of nursing cultural competence, there (John F. Kennedy) currently lacks consensus on theoretical models, definition of relevant terms, or the identification Acknowledgments Thank you to Ms. Taquesha Dean for of skill sets that define competence for clinicians. all of her administrative help during the writing of this Until the nature of this specific competence is chapter. characterized, it will remain impossible to evaluate the situation that defines the point at which a clinician is operating at nothing more than a sat- References isfactory standard. Fulfilling all requirements of safe nursing practice in the performance of 1. Frey WH. Five charts that show why a post-white autonomous decision-making symbolizes an America is already here. The New Republic [Internet]; 2014 Nov 21 [cited 2018 Sep 28]. Available from: entry-level execution of the concept that can be https://newrepublic.com/article/120370/five-graph- applied to mental healthcare. Clinical reasoning ics-show-why-post-white-america-already-here in nursing allows a great deal of latitude in scope 2. Frequently Requested Statistics on Immigrants and of practice as an indication of expertise. On the Immigration in the United States|migrationpolicy. 4 Providing Medical Care to Diverse Populations 73

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Linda R. Zucker

Introduction are in jeopardy at federal and state levels while our collective understanding of the challenges When invited to update the chapter on journalism faced has increased. The media are attacked by for the second edition of this textbook on mental the current Presidential administration in ways health and diversity, a question came to mind that rarely witnessed in US history, yet the media the readership might also have: what wisdom can have opportunities to help shine a light on the journalists impart to mental health professionals ways in which ordinary people may persevere about diversity? What lessons have journalists with hope. It is through these lenses of complex- learned navigating their profession’s changing ity and layers of cultural sensitivity that this landscape that may translate well to those mental chapter aims to make the connection between health professionals? This chapter will look at the journalism and mental health. ways in which journalists may (or may not) take The chapter will discuss the case of into account the many facets of cultural sensitiv- Crownsville State Hospital, where news coverage ity when covering mental health issues. It will that incorporated cultural sensitivity benefitted also address mental health itself as a multidimen- the individuals who lived there. The chapter also sional diversity issue. While those living with addresses the historical case of Nellie Bly, a jour- mental illness are routinely discriminated against nalist who was willing to have herself committed in society, mental illness itself discriminates in order to expose the poor conditions of an early against no one. It affects people of all races, reli- asylum that served women. The author reviews gions, economic statuses, creeds, ethnicities, recent examples of how the print news media cur- gender identities, and sexual orientations. The rently handles stories dealing with mental health political climate has changed drastically in the issues for insight on what is helpful and what is United States since this book was first published potentially damaging or contributes to stigma for in 2014. Healthcare coverage that afforded some individuals living with mental health issues and assistance for those living with mental illness is the providers who care for them. In the wake of quickly disappearing. Protections for LGBT indi- recent celebrity deaths, an analysis of how sui- viduals and families, along with women’s rights, cide is reported in news media and to what extent cultural sensitivity is considered relevant in that reporting is offered. Finally, a look at the #MeToo L. R. Zucker (*) National Coalition of Independent Scholars, movement highlights ways in which social media Walla Walla, WA, USA are enabling cultural change to take place. By e-mail: [email protected] examining case studies, patterns, and histories,

© Springer Nature Switzerland AG 2019 75 R. Parekh, N.-H. T. Trinh (eds.), The Massachusetts General Hospital Textbook on Diversity and Cultural Sensitivity in Mental Health, Current Clinical Psychiatry, https://doi.org/10.1007/978-3-030-20174-6_5 76 L. R. Zucker together we will explore ways that mental health these organizations aims not only to increase the professionals may learn from the evolving world diversity within journalism as a profession but of journalism. The chapter also brainstorms ways also to improve cultural sensitivity by increasing that journalists may collaborate with mental the diversity of reporting on issues that are rele- health professionals to increase awareness of vant to people of different cultural backgrounds. cross-cultural issues within mental health and The Associated Press Style Book also provides help reduce the stigma associated with one of the a basic framework for reporting and colloquial most marginalized populations in society, those usage of terms for news reporting but it is largely living with mental illness. Looking at these cases focused on consistency rather than professional from a journalism point of view, it is useful to responsibility or ethics [8]. Theoretically, we are understand the background of the field and what more accepting of cultural differences and back- motivates the publication of news. grounds today in part because the population in our country is changing over time, so we may reasonably expect that our news environment and A Brief Overview of Journalism stories would mirror this evolution we have experienced. Are there more women and people of News is a consumer-driven field. We inundate our color and LGBTQ people represented in the customers with images, advertisements, news sto- media today? Is there greater coverage of people ries, articles, and information from an early age of different ethnic and religious backgrounds? and nearly every day of their lives. For television The American Society of Newspaper Editors had news, ratings are important; for web sites, the a goal of matching newsroom demographics to number of hits received; and for newspapers, that of the population by the year 2000 [9]. books, and magazines, the number of copies sold. Examining the current landscape of media There is no single governing body setting forth a employment shows that there are still significant comprehensive strategy and direction for our field gaps in these areas and while some areas have providing guidance on what we should do to shown slight improvement, the field did not meet pique the public interest, nor any one set of ethical The American Society of Newspaper Editors’ standards we use to navigate the nuances of cul- goal. For example, according to US Census data, tural sensitivity in news reporting or education. women make up more than half of the population Major news producers tend to have their own spe- [10]. Yet they hold only 39% of all positions in cific ethical guidelines. For example, The the media [11]. Though African-Americans make New York Times has set forth a company policy on up over 14% of the US population, only 4.68% of ethics in journalism that it makes available to the journalists in the United States are black [10, 12]. public. Gannet’s newspaper division implemented An analysis by media watchdog organization the similar guidelines in 1999. In the past two fourth Estate of the front-page news coverage decades, more professional organizations and during the last election cycle reveals that 93% of nonprofits have emerged to provide model ethical front-page print articles about four major policy guidelines to encourage and support journalists in areas—economy, social issues, foreign policy, adopting a global mindset [1, 2], but this typically and immigration—were written by Caucasians does not include guidelines for reporting with cul- [13]. Less than 20% of the writers across most tural sensitivity. The professional organizations major newspaper outlets were black, Latino, and supporting greater diversity in journalism have Asian journalists [13]. The Dallas Morning News developed guidelines for reporting, such as Unity: stood out as a leader in diversity during the 2012 Journalists of Color, the Native American election cycle with 18.8% of their front-page Journalists Association, the National Lesbian & articles written by black reporters [13]. Gay Journalists Association, Arab and Middle Increasing the diversity of journalists may Eastern Journalists Association, the Maynard help to bring new perspectives and cultural Institute, and the Poynter Institute [3–7]. Each of awareness, but larger, systemic shifts may be 5 Cultivating Courage, Compassion, and Cultural Sensitivity in News Reporting of Mental Health During… 77 needed to bring about real change. in her basic biology class in the late 1980s [17]. Newsworthiness is an important criterion in Her teacher gave her few pieces of information whether a story gets published. What makes a about the cells they were experimenting on: they story newsworthy? A story that is interesting were from 1951, the woman they came from died enough to the general public to warrant reporting of cervical cancer, her name was Henrietta Lacks, is the dictionary definition [14]. Events or articles and she was black [17]. Mrs. Lacks’ cells have involving celebrities, politicians, and profes- been used for cancer research, the development sional athletes are often newsworthy. Stories with of the polio vaccine and other drugs, human lon- a local tie or personality may be considered gevity, and more research topics and discoveries newsworthy. Narratives involving drama, con- than can be covered in this chapter [17]. The flict, violence, immediate public health and young Ms. Skloot was upset—“That’s it? That’s safety issues, or new scientific discovery may all we get? There has to be more to the story,” she also meet a definition of newsworthiness. Most recalls thinking and began a search that turned up major media outlets in the United States are little information—a footnote in a biology text- owned by corporations and must be convinced to book, no entries in encyclopedias or other see value in the stories and struggles of ordinary resources [17]. Yet the seeds of inspiration were people living their lives with mental health chal- planted. Ms. Skloot became “fixated on the idea lenges. By reporting on these individual stories, of someday telling Henrietta’s story” [17]. Ms. journalists can help to overcome the stigma asso- Skloot was willing to spend over 10,000 dollars ciated with mental health issues and bring about of her own funds and many months of her own a cultural shift that can contribute to the growth time doing research, getting to know the Lacks and evolution of the mental health system. family and helping family members learn the Journalists, like mental health professionals, truth about what happened to Henrietta, along are human beings who have feelings, beliefs, and with her daughter [17]. Mrs. Lacks died in 1951 backgrounds that help shape the way they see the and very little was known about her until Ms. World. Having this understanding may help jour- Skloot’s research. Few articles were written nalists come to a place of impartiality that is so about Mrs. Lacks and her story was not widely critical to sound news reporting. While impartial- published until 2010 [18–20]. In a Jet magazine ity and neutrality in news coverage is important, article, Dr. J.E. White is quoted as saying “It is some in the field, particularly bloggers, are mak- incidental that Mrs. Lacks was black,” while Dr. ing themselves and their personal motivating fac- W.M. Cobb found there to be poetic justice that tors for reporting (though generally still avoiding an African-American woman would contribute partisan views) more accessible and transparent so heavily to cancer research [20]. A Google to the public through the use of social media [15]. search of Henrietta Lacks returns close to one Rebecca Skloot, a science journalist, took exactly million results—far more than the footnote of the this approach in covering the story of Henrietta 1980s. It is important to recognize that Henrietta’s and Elsie Lacks in her book, The Immortal Life of story did not get told because a newsroom execu- Henrietta Lacks. tive decided this was headline news and deserved prime coverage. In fact, complex issues such as race, economic status, and illness may have all Case Study: Rebecca Skloot contributed to why Henrietta’s story was not fully and “The Immortal Life of Henrietta told before Ms. Skloot decided to make telling it Lacks” a personal priority. Ms. Skloot used several thousand dollars of her own money to fund research Rebecca Skloot’s international best-selling book for the book [17]. Mrs. Lacks was a descendant chronicles the life of the woman behind medical of slaves—a tobacco farmer living in the rural history’s most famous tumor cells [16]. A south at a time when African-Americans still 16-year-old Ms. Skloot learned about HeLa cells faced severe discrimination in medical care and 78 L. R. Zucker employment [17]. She died 4 years before Brown doned 21 German war criminals who were origi- v. Board of Education paved the way for greater nally sentenced to the gallows [18]. By this time, equality in public education. Though the stories of how women, children, people of differ- Nuremberg Code existed at the time of Henrietta’s ent ethnicities, those with physical differences, treatment for cervical cancer, physicians sampled gay, transgender, lesbian individuals, and the her cells and shared her medical records without mentally ill were treated in Nazi Germany during obtaining the informed consent that we recognize World War II had been prominently featured in as a right in today’s world [17]. Mrs. Lacks’ cells US newspapers. It is reasonable to imagine that have made billions of dollars for laboratories American readers may have drawn parallels to while her descendants could not afford basic what they were learning about victims of the medical care [17, 21]. After reading about Mrs. Holocaust and what was being revealed about Lacks’ life and death and the challenges her chil- how people were being treated in their own nation dren face, it is clear that there is a great deal of under the guise of mental health care. injustice in this story. Ms. Skloot’s personal pas- The Crownsville Hospital was known as a sion and desire to communicate this family’s dumping ground for children with mild disabili- story is what brought the history of the Lacks ties [24]. Tuberculosis infections were rampant at family to the public eye. the hospital and in the winter months, there was As part of her commitment to the Lacks fam- no way for those affected by TB to be quaran- ily, Ms. Skloot searched for information on what tined from the healthy residents, likely causing happened to Elsie Lacks, Henrietta’s second the epidemics that occurred there frequently until child. During the research process, Ms. Skloot the late thirties [24]. The hospital served African- discovered some details about Elsie’s brief life. Americans, yet during Elsie’s tenure only one or The information she uncovered provides a win- two African-American staff members worked at dow into the horrific conditions young Black the facility. The hospital would not have any children were subjected to in mental health facili- African-Americans in direct patient care roles ties of Elsie’s time. Elsie was born with epilepsy until long after Elsie passed away [24]. and had an inherited hearing impairment [17]. No Unlike many of the other residents of one taught Elsie sign language, so she was lim- Crownsville, Elsie’s mother visited her weekly ited in her ability to communicate [17]. The year until the cancer treatments prevented Mrs. Lacks before her mother began treatment for cervical from doing so [17]. Mrs. Lacks saw Elsie as clean cancer, Elsie was placed in Crownsville Hospital, and well-cared for during her visits [17]. which was formerly known as the Hospital for However, the children were housed alongside ex- the Negro Insane. The conditions of this institu- prostitutes, criminals, and violent patients with- tion were so deplorable that The Baltimore Sun out regard to safety and well-being [24]. Young published a series of articles entitled “Maryland’s girls were huddled in a playroom that contained Shame,” in 1948–1949 detailing the experiences no toys [24]. There was insufficient funding for of young African-American children in the over- the hospital and the residents lacked proper cloth- crowded facility that Elsie Lacks was likely sub- ing, food, and access to toilets and bathing facili- jected to until her death at the age of 15 [22]. ties [24]. Despite the climate of discrimination What is poignant about the timing of The and racial tensions in the 1940s, The Baltimore Baltimore Sun exposé is that the genocide and Sun dared to report the disparity in treatment tragedy of the Holocaust was still fresh in the between black and white residents at mental minds of Americans. In 1946 and 1947, several health facilities. This in-depth reporting and news employees of Germany’s Hadamar Clinic were coverage led the state of Maryland to allocate convicted of the murders of mentally ill patients increased funding for the residents at Crownsville under the Nazi regime’s notorious T-4 program and inspired the formation of The Golden Rule [23]. The day Mrs. Lacks went to the hospital for Guild, an organization of women mental health tests is the same day that the government par- advocates that still exists today [25]. 5 Cultivating Courage, Compassion, and Cultural Sensitivity in News Reporting of Mental Health During… 79

Ms. Skloot’s journalistic success with the her editors relegated her to the “women’s pages,” publication of The Immortal Life of Henrietta to report on fashion [27]. Dissatisfied, she trav- Lacks highlights a path for propelling a compel- eled to Mexico to report on the customs and cul- ling story into the realm of public awareness. ture of the Mexican people until the Mexican News of her book and the Lacks’ story made government threatened her with arrest for speak- The New York Times best sellers list, along with ing out against the detainment of a fellow jour- being featured on Oprah and in most other nalist [27]. Her work followed a string of press mainstream news outlets [16]. Papers like The stories preoccupied with Blackwell’s Island and New York Times and The Washington Post often its residents [26]. set the standard for journalism and has wide- Women during this time period were particu- spread readership around the world. Millions of larly susceptible to diagnosis of various mental viewers watched Oprah’s show or read articles disorders whether or not they were actually suf- in her popular O! magazine. When CNN or fering from any mental health issues, including other large networks pick up a story, the number female hysteria [28]. Bly feigned mental illness of people who have access to the information by going to a charity home for women and com- increases exponentially. The Internet adds to the plaining that she felt the other women there fanfare and provides countless other opportuni- were crazy and that she was frightened of them ties for information sharing and distribution. [29]. This behavior escalated to speaking in Ms. Skloot made good use of these tools to pro- Spanish, inquiring about lost articles that never mote her book and encourage the public to learn existed in the first place, having amnesia and about the life of Henrietta Lacks. Individual was enough to convince a judge, a doctor, and passion and a willingness to spend her own time several mental health professionals that she and money, rather than the usual profit motiva- should be committed—first to a mental hospital tion that is often associated with journalistic and then transported to the asylum on enterprise, helped Ms. Skloot’s telling of Blackwell’s Island [29]. The asylum at Henrietta Lacks’ story to reach millions of Blackwell was intended to be a forward-think- people. ing facility that was governed by theories of moral treatment but that vision was never realized, with rampant overcrowding. The construc- Case Study: The Asylum tion of the facility only being partially complete, at Blackwell’s Island convicts from the local prison were brought in to supervise and guard the patients [26]. While a In today’s world, the title of Nellie Bly’s book, patient in the asylum, Bly witnessed and experi- Ten Days in a Mad House, does not evoke a enced firsthand the cruelty of the nurses, the sense of cultural sensitivity on its surface. inadequate facilities, and spoiled food [29]. Her Terminology like “mad house” would no longer book details the stories of fellow patients, some be used to describe a mental health facility as of whom were not mentally ill at all but could cultural sensitivity is of greater importance now. not convince the doctors or nurses to take their In 1887 when it was published, it represented a stories seriously enough to reevaluate their female journalist’s act of courage in investiga- admission or status in the asylum [29]. Bly tive reporting and had significant impact on the began to realize that any woman placed into the lives and well-being of women who were institu- conditions at Blackwell in 1887 would develop tionalized at the Women’s Lunatic Asylum at insanity with a little time. Blackwell’s Island. Bly wrote for The New York World, where her What, excepting torture, would produce insanity quicker than this treatment? Here is a class of book was originally published as a series of arti- women sent to be cured. I would like the expert cles [26]. Prior to this, she had reported on the physicians who are condemning me for my action, plight of female factory workers before being which has proven their ability, to take a perfectly 80 L. R. Zucker

sane and healthy woman, shut her up and make her and strike a chord even within the most skepti- sit from 6 a.m. until 8 p.m. on straight-back cal of minds. benches, do not allow her to talk or move during these hours, give her no reading and let her know nothing of the world or its doings, give her bad food and harsh treatment, and see how long it will Additional Modern Mental Health take to make her insane. Two months would make Coverage and Diversity in the News her a mental and physical wreck. Media Ms. Bly would attempt to engage the physicians and nurses about the conditions and was The ways in which journalists frame the news is met with limited compassion mostly from the a critical component of how the stories will be doctors who cared for her during her stay [29]. understood by consumers. “Frames help us to Once in the asylum, the more Ms. Bly acted and make sense of our life experience—they are spoke in a way that was reflective of her normal internal cognitive structures that allow us to self (no longer keeping up the guise of mental locate, perceive, identify and label,” what we illness), the more insane the doctors and nurses encounter [31]. An explanation applicable to the found her to be. Ms. Bly was finally discharged news is that a frame “is the way information is from Blackwell’s Island after an agent from her presented and organized in the media and inter- employer, The New York World, contacted phy- preted by the individual,” [32]. A 2005 study of sicians. Upon release from the asylum, Ms. Bly 70 major US newspapers found that 39% of the was called to testify before a grand jury. During articles discussing mental illness focused on her testimony she spoke of her experiences at various frames around associating mental ill- Blackwell’s Island and the atrocities she witness with the concept of dangerousness [33]. nessed there [29]. Some staff members from Studies have shown that people are influenced Blackwell’s Island who were also called before by what they read in the news and see on televi- the grand jury gave contradictory accounts not sion and that depictions of mental illness as dan- only when compared with Ms. Bly’s story but gerous can increase the stigma associated with also each other’s [29]. Ms. Bly’s journalism and mental illness [34, 35]. If the largest single cat- grand jury testimony helped influence policy at egory of mental health news reporting is around the Blackwell facility [29]. Women were no telling stories that warn of danger of those with longer immersed in cold water to bathe [29]. mental illness, how does this impact the 26% of They were provided with more clothing, blan- stories that are related to treatment and recovery kets, and higher quality food [29]. Dubious from mental illness? [33] If the plurality of practices, such as having a lookout to watch for mental health articles focus on dangerousness, the doctors while the nurses abused the patients, readers may be more likely to dismiss or disas- were put to an end and staff members who sociate from the more positive stories that focus arranged for such things were dismissed from on the benefits and options for treatment and their jobs [29]. Amidst public outcry and insti- recovery from mental illness [34, 35]. tutional embarrassment over the charges, a Mental illness often comes up in the United large allocation of funds—$850,000—was pro- States news as a possible explanation for or con- vided to the Department of Charities and tributing factor to a crime, such as gun violence Corrections [30]. Throughout our nation’s his- or murder [36], even when the perpetrator may tory, journalists like Ms. Bly and Ms. Skloot not have had a diagnosed mental illness. have had the ability to help raise public aware- When looking to other Western nations, the ness and bring important issues to the forefront picture does not get more positive—studies in of civic debate. When journalists report in a Australia, New Zealand, the United Kingdom, way that is inclusive of cultural sensitivity, the Canada, and Germany have yielded similar find- stories have the ability to transcend stereotypes ings [34, 35, 37–39]. 5 Cultivating Courage, Compassion, and Cultural Sensitivity in News Reporting of Mental Health During… 81

There are few recent comprehensive studies access to mental health services were also shown that look at media coverage of mental health between Black and White populations [44]. from a cultural sensitivity perspective, espe- Similar information has appeared in academic cially those done by journalism schools. Most and medical journals before but those articles are of the studies performed in the early to mid- less accessible to the general public. The Internet 2000s on media and mental health appear in makes some free stories more available but many psychiatric and medical journals rather than in academic articles remain locked by pay-per-use literature written by and for the academic jour- fees. The Columbia Spectator serves thousands nalism community. One may speculate that this of students and community members at several is because journalism is frequently about inter- New York colleges and is also available online. viewing and reporting on people and scholarly Another article in the University of Connecticut’s journals are often focused on rigorous academic newspaper explores themes of mental illness topics and perhaps less concerned with individ- being sexualized or depicted in a glamorous ual stories. The mental health community rec- way, particularly when involving female charac- ognizes that cultural awareness and sensitivity ters [43]. Though the readership of a college plays a role in an individual’s ability to seek newspaper may be limited to the academic insti- treatment, and this frame could be useful to tution it serves and the surrounding community, reporters who are covering mental health issues it is encouraging to find that journalists-in- and stories for the news [40]. Recent studies training are willing to address subjects that they include the effect of media coverage on public may have a greater challenge in covering perception of events such as mass shootings post-university. [41], as well as [42]. Additional studies specific “We have to get the word out that mental ill- to mental health and shootings in the United ness can be diagnosed and treated, and almost States are emerging in the fields of law, crimi- everyone suffering from mental illness can live nal justice and forensics. As public shootings normal lives,” is a quote attributable to Rosalynn increase, so does the academic activity examin- Carter, one of the founders of The Carter Center. ing those tragedies; however, the bulk seems to The Carter Center’s compelling motto is, “Waging fall outside of the realm of journalism. Peace, Fighting Disease and Building Hope” [45]. Younger generations are identifying as multi- In addition to the many mental health improve- cultural and may be willing to be more expansive ment initiatives it funds, The Carter Center also in their views of the world. College newspapers offers a fellowship program for journalists from are willing to cover mental health issues and around the world with the goal of helping improve some have done so from a compassionate or the public’s understanding of mental health issues, thought-provoking perspective [43, 44]. One reducing stigma and eliminating the discrimina- example is a thoughtful article published in The tion toward people living with mental health Columbia Spectator in 2009 that emphasizes the issues [45]. The fellowship has resulted in jour- importance of cultural considerations and the nalists having the financial means to publish qual- role they play in determining how and whether a ity work on mental health issues [45]. person will choose to seek mental health treat- The New York Times has a dedicated section ment [44]. The article provides a diverse array of on mental health that sets a strong standard other examples from a Somali immigrant’s family who journalistic institutions could benefit from con- had to consider stigma and superstitious beliefs sidering. Their approach is distinctive because of about mental illness when choosing to seek help its focus on people who are living with mental for their autistic son. It also discusses a Jewish illness—and the emphasis is on living, not the community’s practice to speak with a Rabbi mental illness [46]. In the recent The New York about mental health issues before seeking a men- Times feature, Lives Restored, stories of ordinary tal health practitioner’s help. Disparities in people with mental illness provide hope and 82 L. R. Zucker inspiration for those living with mental illness, as ble at school but did not anticipate that he would well as offer an opportunity for readers to develop end his life [51]. Walker-Hoover’s suicide and empathy and awareness. Two of the five interac- youth bullying was covered in local, state, and tive stories featured have been from people of national news [50–52]. In an effort to begin “…A color who have learned to deal with mental ill- national conversation on bullying,” Oprah ness and live meaningful lives. Stories like these Winfrey spoke with Carl’s mother, along with the are helpful because they demonstrate that mental parents of other bullied teens in May 2009, bring- illness can affect anyone and that there are ways ing in experts to help provide guidance to those of coping that are positive and life affirming, students dealing with bullying in the classroom allowing those impacted by mental illness to [48]. News coverage around bullying has raised have successful professional lives, families and awareness of the prevalence of anti-LGBTQ bul- contribute to society and their own sense of well- lying in the schoolyard and online [53]. Ten or being. The interactive feature format allows read- twenty years ago, it may have been hard to imag- ers to see footage of the people, putting a face on ine a national dialogue around student safety and common mental health concerns, hear the voices anti-LGBTQ bullying. Now, institutions like of diverse backgrounds and lives, and read more Michigan State University School of Journalism extensively about each person’s story in a more are taking the initiative to raise public awareness traditional webpage article. of bullying through news coverage projects and book authorship [54, 55]. CNN reporter, Anderson Cooper, who is openly gay, won an Case Study: Youth, Bullying, award from the National Gay and Lesbian and LGBTQ Issues Journalists Association in 2012 for his Anderson 360 series titled “Bullying: It Stops Here” [56]. Students will hear anti-gay bullying or gender- With the increased attention and focus on the based slurs up to 26 times per day at school [47]. impact that bullying has on young people, legis- This type of bullying affects not only those stu- lators at state and national levels are closely dents who identify as lesbian, gay, bisexual, examining what can be done to help reduce and transgender, questioning or queer (LGBTQ) but eliminate the sources of harm by making schools also has an effect on all students. Being bullied safer places. Massachusetts’ anti-bullying legis- on the basis of sexual orientation is a form of lation went into effect on May 3, 2010 [57]. sexual harassment, according to Dr. Dorothy Espelage, a University of Illinois professor [48]. Bullying creates an unsafe environment for chil- Case Study: Mental Illness as White dren to learn and to thrive in. Massachusetts, like Privilege many states, has witnessed the effects of bullying on school children. Previously, we have examined ways in which In 2009, 11-year-old Carl Joseph Walker- mental illness is used by the media to disparage Hoover hanged himself by an electrical cord in or create fear of those with mental illness. his Springfield, Massachusetts home while his However, mental illness can also be used by the mother cooked dinner [49]. The African- media to explain away the motivations of people American preteen did not identify as LGBTQ, who commit reprehensible crimes. It is important but was teased relentlessly by his peers at school to define what is meant by white privilege. being called gay or effeminate [50]. His mother TeachingTolerance.org has the following to say worked to ensure that the school was aware of the about white privilege: “White skin privilege is bullying and joined the local Parent-Teacher not something that white people necessarily do, Organization in an effort to put an end to it [51]. create or enjoy on purpose. Unlike the more overt She was aware that her son’s behavior had individual and institutional manifestations of rac- changed and that he was getting into some trou- ism described above, white skin privilege is a 5 Cultivating Courage, Compassion, and Cultural Sensitivity in News Reporting of Mental Health During… 83 transparent preference for whiteness that satu- training, so reports ascribing mental illnesses to rates our society. [58]” The concept of white white shooters are more often based on specula- privilege is one that can ignite controversy and tion rather than facts. Additionally, a June 2018 denial, yet it is important to look at in the context FBI report which examined the pre-attack behav- of news reporting of crimes. When journalists iors of active shooters in the United States for a cover active shootings in the United States, racial, period of 13 years found, ethnic, and mental health stereotypes are often Some studies indicate that nearly half of the U.S. implicated. [59] conducted a study to review a population experiences symptoms of mental ill- sample of 170 stories, in which the words “men- ness over their lifetime, with population estimates tal illness” were used to describe white shooters’ of the lifetime prevalence of diagnosable mental illness among U.S. adults at 46%, with 9% meeting behaviors 80% of the time, yet only 16% for the criteria for a personality disorder. Therefore, black and 4% of Muslim shooters. When report- absent specific evidence, careful consideration ers portray mental illness as the cause of a shoot- should be given to social and contextual factors er’s actions, they are promulgating a narrative that might interact with any mental health issue before concluding that an active shooting was that the shooter is more entitled to compassion or ‘caused’ by mental illness. In short, declarations understanding than if they were to portray that that all active shooters must simply be mentally ill same shooter as a thug or as a terrorist, which are misleading and unhelpful, [62]. was overwhelmingly the case for non-white To facilitate a more fact-based dialogue, jour- shooters [59]. The Washington Post noted that nalists must be willing to face their own biases language used by mainstream news media outlets and understand how those biases shape the news to describe Dylan Roof, who shot nine African- they report. In 2017, there was a record number American churchgoers, centered around the idea of 30 active shootings in the United States [62]. that Roof was “mentally ill” in an effort to Journalists have a responsibility to transform humanize the white shooter, rather than refer to harmful narratives that reinforce dangerous racial him as a terrorist who targeted peaceful, praying and ethnic stereotypes. Mental health profession- minorities because of the hatred he had for them als have an opportunity to partner with journalists [60]. They cited other examples where reporters to help them understand mental illness and the portrayed white shooters as “mentally ill,” while role it does or does not play in violent events such black victims of shooters were described as vio- as mass shootings. lent or somehow culpable for or contributorily negligent in their own deaths, even when those victims were children [58, 59]. This tendency to vilify non-white victims is troubling and shock- The #MeToo Movement ing to the conscience. It is difficult to compre- hend what purpose this style of reporting has that Tarana Burke, a sexual assault survivor who serves any public good or even newsworthy pur- sought to help other women and young people of pose, other than perpetuating a racist narrative. color who had also survived sexual violence, Shooting victims who are Caucasian are not vili- started the MeToo Movement in 2006 [63–65]. At fied in this manner or held responsible for their that time, approximately 5% of Americans used own deaths. One can argue that it is inappropriate social media [66]. Over a decade later, social for journalists to diagnose the mental health of media use jumped to nearly 70% of Americans their news subjects unless the information is and #MeToo began appearing on social media in coming from a psychiatrist or psychologist famil- connection with stories of sexual assault and iar with the individual, which would likely give harassment experienced by celebrities. High- rise to physician-patient confidentiality issues profile cases in film, television, US gymnastics that would prohibit reporting on such material and politics emerged, along with stories of every- [61]. One study found that very few media profes- day women all over the world. Social media sites sionals had received any mental health awareness became platforms for women to break their 84 L. R. Zucker silence around sexual violence and also enabled page or headline news, as witnessed with the males and other genders to witness these stories June 2018 deaths of fashion designer Kate Spade and offer support. The visibility of #MeToo and and author, TV personality, and culinary ambas- the women sharing their experiences also helped sador Anthony Bourdain [70, 71] or comedian to highlight the amount of trauma that many Robin Williams’ death in 2014 [72]. There are women from all walks of life are living with [67]. differing opinions about how much information Within the first 24 hours of #MeToo going viral, should be covered when a suicide has occurred over 12 million people engaged with the hashtag [73]. Journalists are advised to be aware that on Facebook alone [64]. The coverage was not news of suicides can inspire copycat behavior in completely positive, as many comments scrutiniz- others who are contemplating suicide and to ing the clothing women wear, how women behave, avoid reporting that could be interpreted as having male friends, whether a particular woman romanticizing the behavior [73]. What is less was believable also emerged in the discussion, known about these stories is to what extent the which can have the effect of re-traumatizing sur- reporter covering them has taken cultural sensi- vivors of sexual violence and distorting or shifting tivity into account. Suicide is a topic in some cul- the focus away from the causes and perpetrators tures that may not receive adequate attention of violence [67]. The pace at which the movement because of personal or societal beliefs that either grew caused a risk of the original voices behind condone or condemn personal acts of suicide. #MeToo being drowned out. Using the same Journalists may want to be sensitive to these cul- social media platforms that many Caucasian tural nuances and how they may affect the com- women were leveraging to speak about their expe- munities, families, and groups dealing with the riences, Tarana Burke was also able to voice her aftermath of a suicide. Suicide carries with it concerns about women of color being included in great pain for the families and friends left behind, the conversation that they started long before the as well stigma that is pervasive in American soci- viral social media hashtag gained traction [64, ety and many additional cultural backgrounds. 65]. The movement gained so much attention that President Obama recently ended the military’s Time magazine named The Silence Breakers, practice of not sending condolence letters to the acknowledging Tarana Burke and several others families of service members who took their own in the #MeToo Movement as its 2017 Person of lives, in part to “de-stigmatize the mental health the Year [68]. By January 2018, over one million costs of war to prevent these tragic deaths.” Some people marched in Washington D.C. for the sec- religions believe that suicide is immoral or an act ond annual Women’s March “to harness the politi- against creation [74]. One study suggests this cal power of diverse women and their communities may have a beneficial effect in the course of treat- to create transformative social change,” [63, 69]. ing individuals with bipolar disorder due to the As of the publication deadline for this textbook, closer-knit religious communities helping indi- more allegations have surfaced, investigations are viduals feel less isolated and more likely to seek taking place, conversations are occurring on pre- help and support [74], though for individuals vention and treatment and perpetrators are with other mental health issues, a moral or reli- increasingly being held accountable for sexual gious stigma may not be a helpful factor. For the violence. surviving family members of those who have lost loved ones to suicide, this type of stigma may prevent them from receiving the care they need to Cultural Sensitivity in News Reports cope with their grief [75]. Some religions have of Suicide changed their practice or doctrine around how to treat suicides and offer hope and help for families A mental health topic that tends to receive strong and friends by taking into account mental illness coverage is suicide. When a celebrity or profes- [75]. There has also been some journalistic effort sional athlete commits suicide, it makes front- to dispel the myth that African-Americans don’t 5 Cultivating Courage, Compassion, and Cultural Sensitivity in News Reporting of Mental Health During… 85 commit suicide. Journalist Amy Alexander and contact information for the National Suicide Harvard Psychiatrist, Dr. Alan F. Poussaint co- Prevention Lifeline and encouraged readers or wrote the book Lay My Burden Down: Suicide viewers to seek professional help if needed. The and the Mental Health Crisis Among African- Poynter Institute also reminded the news media Americans [76] in which they explore their that there is opportunity to reinforce a message of respective, deeply personal experiences with hope during these times that may help others con- family members who committed suicide, along sidering suicide [84, 85]. The final section of this with the broader cultural and societal factors that chapter will explore ways that journalists can contribute to a disparity in mental health treat- improve professionally, as well as how mental ment for African-Americans. The book received health professionals can benefit from or be a part broad coverage when it came out in 2001 with of that process. prominent features in The New York Times and Washington Post [77, 78]. Follow up stories on NPR and a blog for The Clarion Ledger newspa- Opportunities to Improve Efforts per leveraged Poussaint’s expertise [79, 80]. Around Mental Health and Cultural When Don Cornelius the creator of the popular Sensitivity in the Media 1970s show Soul Train committed suicide in 2012, the issue of African-American beliefs In Zanzibar, the Muslim community has a prac- around suicide were raised once again, with tice of helping people whom Westerners would Clarence Page, whose ex-wife had earlier taken diagnose as schizophrenic primarily through her own life, stepping out with a call to “shatter compassion, support, and inclusion [86]. Words the black suicide myth” [81]. of the Qur’an are written on the inside of their In both cases, the journalists’ willingness to cups so they drink the words of healing [86]. The share their personal stories brought attention to a community believes in appeasing the voices with mental health issue. This is precisely what hap- dance and song as a means of healing, so the indi- pened with both Nellie Bly and Rebecca Skloot— vidual is exposed to art and activities with others where the individual journalists’ own reasons for that they would likely be excluded from if were reporting the news provided the foundation for they coping with schizophrenia in Western cul- elevating mental health issues to a place of greater ture [86]. This story came from an academic jour- public awareness. nal, not a work of news journalism, yet it provides There are ways for journalists to report with an intriguing model for the different ways jour- integrity and ethical standards that can also sup- nalists may want to choose to cover stories port broader cultural shifts. News reporting stan- around mental health. One way to provide unique dards for journalists that include cultural coverage to mental health professionals may be sensitivity and awareness may lead to greater to look at the history, traditions, and cultures of public awareness. The Poynter Institute, in part- people in and outside of the United States for nership with several mental health organizations, insight and information. This approach could has helped publish Recommendations for prove useful for mental health professionals, as Reporting on Suicide that have been featured on well. What is acceptable by our larger society CNN and other major media outlets [82, 83]. today was not necessarily acceptable decades Included among them are using neutral headlines ago, nor is there any guarantee that what is and photos of the individual, describing suicide acceptable today will be tomorrow. American trends accurately rather than sensationalizing, culture is a melting pot of the indigenous peoples using passive voice, including information on the who originally lived here, along with the many warning signs of suicide and messages of hope, peoples who have found refuge here throughout and including information on prevention [82, 83]. the centuries. Rather than dismiss different belief With the deaths of Anthony Bourdain and Kate systems, journalists and mental health profes- Spade, much of the media coverage included the sionals may want to carefully seek to understand 86 L. R. Zucker the allegory, symbolism, and wisdom that each that direction. News organizations could amend has to offer because this directly relates to our their standards to be inclusive of cultural sensitiv- ability to effectively and accurately tell the sto- ity and provide training to existing staff that ries of the people we represent. Through under- emphasizes the importance of diversity in report- standing the traditions, beliefs, and practices of ing as well as our global society. different nations and cultures, journalists and On an individual level, journalists may seek to mental health professionals may also find practi- partner more closely with mental health profes- cal and unexpected guidance on how to approach sionals to inform perspectives on a story. Scholars the topic of mental health more creatively and and physicians alike believe that integrating mental compassionately in the art of telling peoples’ sto- health professionals into journalism as experts or ries or creating a nonjudgmental and inclusive commentators could greatly improve the aware- environment for a client to tell his/her story. ness that the journalist has on the particular mental Journalism schools need to take a greater role health issue being covered but may extend to a in teaching topics of diversity, cultural sensitiv- more balanced story reaching the public, as well ity, and mental health in their academic institu- [87]. Greater collaboration and interaction between tions and increase research in the industry to mental health professionals and journalists may understand the news being produced. The avail- help inspire the kind of personal passion necessary ability of news via blogs and the Internet opens for helping elevate issues and stories to a larger up so much potential for understanding and audience. Mental health professionals’ input in the information sharing. Modern journalism research media may help reduce the stigma associated with could uncover more promising data on the diver- mental illness and increase the data available to the sity of the profession. Research is also critical to public about options for treatment. inform educational practices and teaching needs Concluding this chapter without a mention of a that could translate well to the university class- growing and controversial population of reporters room environment. Better research could lead to would overlook contributions that the populace an increase in funding for fellowships or other can make to journalism, mental health, and cul- educational initiatives that offer experiential- tural sensitivity. Ordinary citizens may help pres- based learning opportunities for journalism stu- ent creative ways to cover challenging topics dents to get real-world reporting and editing something from which both journalists and men- exposure in a climate that enables them to incor- tal health professionals can learn. Almost anyone porate cultural sensitivity in the newsroom. can become a journalist today with the prevalence Several journalism schools in the United of and reliance on the Internet, social media, and States have formed ethics centers or programs of blogs. With confidentiality and protecting health study, such as The University of Michigan, The information, mental health professionals can take University of Wisconsin and Santa Clara their own initiative to share knowledge or exper- University. Cultural sensitivity may be a comfort- tise by starting online communities, blogs or regu- able fit within an ethical paradigm. If budding larly contributing to local news media. journalists have a greater understanding of the Performing a search on a mental health topic importance of cultural sensitivity, then this and the words “personal stories,” yields hundreds knowledge can be woven into the reporting they of thousands of results and that list is growing carry with them to internships and later, the pro- daily. With the experience of mental health issues fessional arena. touching such a large portion of the population, we More news organizations could take the can come to understand the faces and stories asso- approach of The Dallas Morning News and ciated with mental illness through firsthand extend opportunities to journalists of diverse accounts. This openness of the very people living backgrounds. Having a more diverse workforce and sometimes struggling with mental health alone will not necessarily improve the quality of issues may yield greater understanding, so that the coverage of mental health issues but it is a step in level of tolerance and inclusiveness can increase. 5 Cultivating Courage, Compassion, and Cultural Sensitivity in News Reporting of Mental Health During… 87

Voices that are not as prominent in the news media, power of hearing from someone who was once in such as those of minorities, can still be heard or the same place but is now grateful to still be alive. read online. If people make a concerted effort to Telling their stories in a recorded format or others get to know their stories and bear witness to the coping with similar problems could also be uniqueness, beauty, and authenticity of cultural cathartic for the patient. People with obsessive- influences, we become aware of the great capacity compulsive disorder have been shown to improve we human beings possess for healing and resil- when they can help others with the condition. iency in many areas, including mental health. And Doing something for others and getting out of it is precisely these stories—both from profes- one’s own world can be extremely helpful to peo- sional and amateur writers—that may provide the ple with mental health conditions. best lesson for mental health professionals. The The stories of journalists like Rebecca Skloot, personal testimonials and journalistic anecdotes Amy Alexander, and Nellie Bly, as well as the ethi- are powerful because they tell stories of adversity, cal guidance and journalism best practices pro- triumph, bravery, dedication, love, passion, and vided by the Poynter Institute, demonstrate the heroism. We are all wired to listen to and respond power of presenting news from a place of courage to stories, as academic research has repeatedly and integrity. Their willingness to expose critical shown [88]. In one recent study, researchers at issues contributed to gradual perceptual shifts in University of Massachusetts Medical School public awareness that had real effects on those liv- found that patients were more successful at con- ing with mental illness, as well as helped tackle trolling their blood pressure if they heard stories of serious questions around racial bias and inequality, other people who had succeeded at the same setting a strong example for other journalists. thing—rather than reading a pamphlet telling them Journalism has many more opportunities for com- the proper steps to take [89]. (The study was later passionate coverage that can shine a light in places nominated by the Robert Wood Johnson previously kept dim. The author hopes that mental Foundation as one of the 20 most influential health professionals may also be willing to contrib- research articles of 2011.) Ben S. Gerber, M.D., ute their expertise toward greater cultural under- M.P.H., an associate professor of medicine at the standing of mental health through news reporting University of Illinois at Chicago, believes stories and by inspiring patients to creatively share their can help medicine in at least four ways: (1) articles stories in ways that can be healing and empowering can provide basic information in a more compel- for all during these challenging times. As Howard ling way than a brochure; (2) stories can offer Zinn said, “To be hopeful in bad times is not just emotional support, showing the patient that they foolishly romantic. It is based on the fact that are not the only one with a particular problem; (3) human history is a history not only of cruelty, but stories can model behavior, such as sticking to an also of compassion, sacrifice, courage, kindness. exercise program; and (4) they can help people What we choose to emphasize in this complex make decisions about which treatment plan is best history will determine our lives. If we see only for them, by offering a nonmedical view of the the worst, it destroys our capacity to do some- pros and cons of a particular approach [88]. thing. If we remember those times and places– Mental health professionals could use story- and there are so many–where people have telling when prescribing treatment, for instance. behaved magnificently, this gives us the energy to Particularly for drug regimens that require some act, and at least the possibility of sending this tinkering to get right, as with attention deficit spinning top of a world in a different direction. hyperactivity disorder, it could make a difference And if we do act, in however small a way, we for a patient to hear how a previous patient per- don’t have to wait for some grand utopian future. sisted despite difficulties until they reached an The future is an infinite succession of presents, effective and helpful dose. For people with and to live now as we think human beings should depression who are considering suicide as their live, in defiance of all that is bad around us, is only escape from a miserable life, imagine the itself a marvelous victory” [90]. 88 L. R. Zucker

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Schuyler W. Henderson

Introduction some years at the end of the last century, it seemed that in the United States and Europe, Immigration has a unique relationship to the field immigration and migration status was going to of mental health: many of the prominent early play a less prominent political role, while interest figures who shaped contemporary mental health in the social (and health-related) consequences of were themselves migrants—from the Freuds and race, gender, and sexuality became more promi- Erik Erikson to Eric Kandel and Leo Kanner— nent while thinking around these topics became and some of the earliest and most important stud- subtler; though immigration has always provoked ies that formed the initial evidence base for the disagreement and political complaint, it seemed practice of mental health, particularly in child to have settled into something that was often rec- psychiatry, involved immigrants. Indeed, immi- ognized to be a good thing much of the time. grants have long been drawn to work in the field Rates of migration and acceptance of refugees of mental health, though often facing prejudice as into the United States, for example, appeared to they do so [30]. All of this is to say that immigra- be on the rise [27, 40]. Over the past few years, tion is not simply a demographic characteristic of however, immigration has again become one of patients contributing to their psychosocial profile the most bitterly fought social issues. The United or that can come under the microscope in mental States has been called a “nation of immigrants” health (as a stressor, as a variable, as a mediator (indeed, that was the title of John F. Kennedy’s or moderator of outcomes, as a cultural factor to final book [21]), but in the twenty-first century, be accounted for): immigration has played a role this same term “nation of immigrants” became in shaping what we know about mental health increasingly necessary not so much as a reminder and how we know it. of a shared past but as a way of countering And yet there is no doubt that immigration increasingly exclusionary and bigoted anti-immi- remains a hotly controversial political topic. For grant rhetoric (as in Barack Obama’s address to the nation in 2014 [25]). As the population of the United States became, proportionally, increas- S. W. Henderson (*) ingly foreign born, and as migration (particularly Department of Clinical Psychiatry, New York from Northern Africa and Turkey) increased in University, New York, NY, USA Europe, and alongside the so-called war on ter- Department of Child and Adolescent Psychiatry, ror, Islamophobia, the reality of terrorism, and Child Study Center, Bellevue Hospital, New York, NY, USA with the success of increasingly xenophobic poli- e-mail: [email protected] ticians (such as the “Americans first” policies

© Springer Nature Switzerland AG 2019 91 R. Parekh, N.-H. T. Trinh (eds.), The Massachusetts General Hospital Textbook on Diversity and Cultural Sensitivity in Mental Health, Current Clinical Psychiatry, https://doi.org/10.1007/978-3-030-20174-6_6 92 S. W. Henderson under President Donald Trump [38]), immigra- reported; this is not a universal rule in health care tion has again become violently controversial. settings, and practitioners should know their set- Anti-immigrant rhetoric (such as the frequent ting’s rules on this and, if necessary, disclose claim, e.g., that immigration increases the risk of them before obtaining information that could put violence, including terrorism and sexual vio- their client/patient in jeopardy. lence) and anti-immigrant policies directly affect The National Immigration Law Center has people and therefore directly affect clinical provided a useful guide for practitioners offering encounters [35]. Broadly, anti-immigrant rheto- advice (which they acknowledge cannot consti- ric and policies depress access to mental health tute legal advice) on how to address immigration services and increase stressors in immigrant pop- officials and officers who may attempt to enforce ulations, both of which have significant public immigration laws in a health center, including health effects; more specifically, these pervasive ensuring that patient information is protected or cultural attitudes make conversations around not accidentally disclosed [24]. immigration more difficult, even in confidential Clear policies that are visible, legible, and or supposedly neutral settings. understood by all the practitioners and support It is nevertheless important to address immi- staff in any clinical setting are required so that gration when working with any migrant popula- someone accessing mental health care will know tion, and though there may be a shared discomfort what they can or cannot disclose as they seek in broaching the topic, the responsibility is on the care. mental health clinician to become more comfortable obtaining an immigration history, allaying or addressing any concerns the immigrant has about Models of Migration safety and security, and ensuring that the immigrant understands the extent to which discussing While migration status is often categorized by his or her immigration status is a safe topic. legality (such as determining if someone is an “illegal alien”), and while this legality may be the most significant factor—and stressor—in terms Safety First of a migrant’s current mental status and psychological safety, legality itself says little about the Beyond simply the cultural and political contro- process of, and rationale for, migration. versies around immigration, there are potential immediate legal consequences to a disclosure of immigration status—whether one’s own or the Voluntary and Involuntary immigration status of another member of the family, such as a parent reporting on a child’s sta- Migration is often viewed as either voluntary or tus, or a child on an uncle’s, for example. These involuntary (forced) migration. Voluntary migra- legal consequences for disclosure or discovery of tion typically involves economic or employment- certain immigration statuses (or, to put it more related migration, from the vast number of bluntly, being officially identified as “illegal”) agricultural workers (thought to number in the may include family separation, detention and millions of migratory farm workers in the United deportation. This means that in addition to per- States [23]) or construction workers who travel sonal sensitivity around the subject, clinicians across national lines to build skyscrapers and need to disclose whether they are able to keep homes, to the expertise-related migration of engi- information around immigration status neers and physicians or graduate students. Family confidential. reunion is another voluntary reason for migra- At the hospital where I work, immigration station, as families come together around employed tus is not formally obtained and those without family members (sometimes disparagingly current legal immigrant status will not be referred to as “chain migration,” even by people 6 Illegal, Alien, and Other: Cultural Competency and Migration 93 who themselves have this “chain migration” in tors can be clear (coming to a job at a university, their own history). to reunite with a partner) or difficult to express Involuntary or forced migration refers to peo- (dreams of a better life, a desire for something ple who are forced to leave their country of origin new). due to violence, persecution, fear of persecution, It is worth remembering that even within a or environmental disasters. One such population single family, there may be different legal sta- is the “refugee,” defined legally as someone who: tuses, and certainly different narratives about rea- owing to a well-founded fear of being persecuted sons for migration, as well as different push and for reasons of race, religion, nationality, member- pull factors. One refugee family in the 1990s ship of a particular social group or political opin- demonstrated this when the teenage children, for ion, is outside the country of his nationality and is example, were thrilled to be in Chicago for the unable, or owing to such fear, is unwilling to avail himself of the protection of that country; or who, music scene while the parents were profoundly not having a nationality and being outside the distressed by their inability to find work com- country of his former habitual residence as a result mensurate with their skills in their native Bosnia, of such events, is unable or, owing to such fear, is though all had fled Bosnia together and all could unwilling to return to it. [39] similarly describe the atrocities they had wit- Although “refugee” is a well-recognized legal nessed and the fears they felt. status, people who have fled their country of origin may not have qualified for the designation because of political decisions made on a global The Tripartite Model scale or decisions made by immigration officers when they are seeking asylum. In discussing models of migration, another way But the distinction between voluntary and to conceptualize migration other than legal status involuntary migration is not always clear cut. Of and through understanding the rationale for course, there are multiple reasons for migration, migration is to look at the different phases of and “voluntary” migration may not be voluntary migration; an advantage of considering this insofar as economic disadvantage, global ineq- model is that in this tripartite model, there are dif- uity, and social injustice may drive people to ferent associated psychosocial stressors, which work in another country (where they are fre- can be usefully elucidated. quently vulnerable and exploited), and the quest The first phase is “pre-migration,” the period for “refugee” status is denied to many who are before migration. The stressors are often ones fleeing persecution. precipitating departure, including poverty, fam- ine, environmental disasters, war, systematic persecution, and other systematic violence, such as Push and Pull Factors gangs, political oppression, and domestic violence [28]. These stressors can directly impact In discussing the rationale for migration with children’s and families’ development, disrupting someone, the focus should be less around a single employment and education, resulting in physical motivation, and rather an attempt to understand danger, somatic and psychiatric morbidity, and in the diverse factors that cause someone to move stressing family relations. from one place to another. One way to think The second phase is “migration,” the move- about this is in terms of “push” and “pull” fac- ment itself. The stressors here include psycho- tors: the factors pushing someone away from a logical stressors (loss of a homeland, exposure country of origin and pulling them into a new to dangerous situations, uncertainty) as well as country. These push factors can be obvious (such the dangers inherent in migration (exploitation, as unemployment rates, persecution, poverty) or exposure to human trafficking, victimization) subtle and personal (such as getting away from and family separation, as when children are not obnoxious relatives), and similarly the pull fac- accompanied by parents or when they are forci- 94 S. W. Henderson bly removed from their parents [7, 13]. For not (e.g., whether a child is with parents or a example, Suárez-Orozco et al. reported that child has been left behind with grandparents); 85% of adolescents from Central America, a migration narrative typically entails separa- China, the Dominican Republic, Haiti, and tions, some of which are tremendously stress- Mexico had been separated from parents for ful, but may also involve important reunions extended periods and that this separation was (which can be stressful: I knew one child associated with subsequent depression in these whose mother had come from a Central youth [33]. American country to join her 8 years after the The third phase is “post-migration,” which girl had left that country, and the mother and follows the arrival in the destination country. daughter had both typical joys and complaints Stressors here include the nature of the arrival about one another, but had to negotiate a very (whether there has been detention, e.g., or forced complicated relationship around limit-setting, family separation), as well as the challenges of with a child unused to a mother who was now re-settling in a new environment, such as learning setting rules for her). a new language, negotiating new cultural expec- • Identifying strengths: If one thinks about how tations, exposure to stigma, the effect of policies difficult it can be to move from one apartment and cultural attitudes around migration, and to another, one may have increased sympathy accessing necessary systems, including educa- for the immense strength it takes to move from tional and health care systems [4, 37]. one country to another. Rare is the migration story that does not in some way highlight a person’s resilience, courage, and capacity to Acknowledging the Journey survive. • Identifying potential cultural differences: The If a discussion about migration status can safely migration story not only explains an event and proceed, there are a multitude of ways of talking how a person is connected to, or not connected about migration and a multitude of frameworks to, family members and communities, but it for understanding the journey and its effects. will begin to give the listener an insight into Throughout this chapter, in the hopes of covering potential cultural challenges in language, clinically relevant issues that arise around migra- resources, expectations, and experiences. tion, one of the key points is that stories about • Identifying potentially relevant recent or dis- migration will unfold like any narrative: they will tant stressors: While migration stories may be be personal, complicated, consistent with some positive and clear (as when someone makes a expectations and inconsistent with others. decision to move for educational reasons, One way to begin understanding the role of obtains a visa, and comfortably re-locates), migration is to obtain a migration history. others may involve more complicated experi- The reasons for obtaining a migration history ences or frank trauma, even multiple episodes include: of trauma. • Identifying current stressors: Past trauma • Understanding the person: Migration is usu- before or during migration is important to ally a very significant event in a person’s life, elicit, but current stressors, including ones rarely indulged in frivolously, often involving related to education, employment, and family, both resilience and loss, and can be a centrally can be the most closely correlated with current important feature in a person’s life. Leaving mental health. Practically speaking, although one’s home is almost universally a normative past events may be more horrifying, current developmental experience; leaving one’s stressors may be the ones that are most press- homeland typically involves difficult decisions ing and need to be addressed first. and, even when forced, some degree of intent. Treatment planning: The migration story can cer- • Understanding relationships: Migration tainly include a psychiatric history of treat- shapes who one lives with and who one does ment (such as having had treatment in one’s 6 Illegal, Alien, and Other: Cultural Competency and Migration 95

home country), but can also be important to entail frequent travel (such as agricultural allow for a fuller discussion of ongoing migra- workers), it is also true that a migration narra- tion plans, such as plans for moving on to a tive may include plans to return to a country of different city or even different country. origin or to move on to other countries. Furthermore, the connections with the home As when telling any personal history, some- country should be considered: this includes one’s telling of their stories will be shaped by what sort of connections are being maintained trust, expectation, and relevance—and given the and lost, what sort of contact people are having controversy around migration and “legality,” (especially in this era of widespread electronic this sensitive topic may not be wholly disclosed connectivity), and what sort of roles and respon- during an initial encounter. In order to elicit a sibilities are being maintained (such as when migration history, you can consider asking someone is making money to send to family about: back in their country of origin).

• The journey (where they originated, where they moved to, how they arrived, where they Home are now): Where did you come from? Did you come directly here? How did you leave? “Home” defines and shapes and creates who we Where did you stay along the way? are, through our relationships, the extent to • Reasons for migration: When did you start which we do or do not belong, the things we are thinking about leaving? What were some of familiar with, and the ones that seem to come the reasons for moving? What ultimately from outside; home is where we learn lan- made you decide to move? When did you guages, cultures, and rituals which come from know you were going to leave? the larger world but are inflected, shaped, and • The extent to which it was voluntary or forced: experienced in a private way. When one answers Did you have a choice about where you were questions about where one is from, the answer coming? Did you want to come here? is always a variant on “home.” As described by • Whether the journey is understood to be com- Henderson, Sung and Baily [18]: “Migration plete (for example, whether a return to the complicates and challenges simplified notions native country is anticipated or further move- of home. With migration, we may have multiple ment for employment, family reunification): homes, multiple places we come from, multiple Do you plan to return? Do you hope to return? cultures and societies in our backgrounds, shift- Do you want to stay here or do you see your- ing and changing and developing and intermin- self moving on? gling. As such, migration can have a vast array of meanings—legal, psychological, and psychopathological.” Challenges to Assumptions Being open to this plurality of meanings without necessarily being fixed to assump- In thinking about cultural competency in relation tions is the most generous and productive to immigration and obtaining a migration history, stance when listening to people talk about there are a number of assumptions about migrant their home. At the same time, it is necessary to communities that should be addressed. remember that the question “Where is ‘home’ for you?” may well have the answer, “Here.” Whether welcomed or not, migrants will to The Permanence and Totality some extent have adapted and absorbed some of Migration of the customs and traditions of the society they are now in—a society inevitably influ- Migration may not be forever: although this enced and shaped by countless prior may be more obvious with migrants whose jobs migrations. 96 S. W. Henderson

Diversity Within Diversity There are a number of issues that arise around language, particularly in migrant families: the It is extremely important to remember that there can extent to which the children and parents share (or be immense diversity between, and within, migrant do not share) language skills and fluency can populations and that migrant status and country of result in conflict. When members of the family origin are only broad indicators of demographic and are not fluent, it is well-established that an intercultural orientation. Indeed, within migrant popula- preter should be used, without assuming that the tions, ethnic and socioeconomic status can be highly more fluent members can or should interpret in variable [1]. For example, although a population place of a professional interpreter. may qualify as “refugees,” even within that popula- Once again, language is an issue that can and tion there will be multiple individual reasons for should be specifically addressed. When meeting migration (push and pull factors), and these may one or more members of a family, it is important differ within communities or families, as can legal to identify these generational differences. Can, statuses (there was a child in our program whose for example, a grandparent function effectively uncle was deported when caught by immigration outside of his or her language community? Or, as services; she herself was not under threat of depor- another example, can both parents attend parent- tation as a citizen). child conferences and understand the teachers? And of course, within migrant populations, Which adults can decipher report cards or help there will be diverse educations, diverse pre- the child prepare for college? migration and post-migration employment expe- Without trying to marginalize or belittle the riences, and diverse experiences of persecution migrants’ language skills, it can be important to and safety (e.g., someone who has migrated for not just identify language competency in the host the “economic” reason of obtaining high-tech nation’s language(s) but barriers to learning that employment in Silicon Valley but was also a vic- language, including cost, availability of tutors, tim of gender-based violence). willingness/ability to learn a new language. Being unable to speak a dominant language can result in isolation, marginalization, and ensuing social dif- Language ficulties (including communicating with officials, obtaining appropriate papers, etc.). While it can Similarly, in addition to being cautious about cul- be important and culturally valuable for children tural assumptions based on country of origin, so to learn the language of their parents and losing caution must be exercised when assuming that use of one’s original language may be a risk factor because someone is from a particular part of the for psychopathology [9], competence in the lan- world, they speak the dominant language there. guage of the country the children are living in has In a New York City clinic, some of the Central been shown to predict social functioning as well American and Mexican migrants do not speak as academic performance [36]. Spanish as a first language, and this also happened when children separated by Trump, Sessions, and Nielsen from their parents at the Stigma border were placed into detention centers or with agencies who had Spanish speakers but nobody Who are we meeting when we encounter who could speak local dialects and hence were “migrants”? Given that the term is not all- unable to communicate with the children. It is inclusive or all-explanatory, one should neverthe- then important to assess what languages are spo- less be aware not just of how migrants are lumped ken by each person, which languages are spoken together, but how the concepts and language of in the home (can the children, e.g., understand lumping have effects. The language one chooses their parents?), and levels of fluency and compe- is itself important and can import assumptions tency in the language(s) of the host country. that are clinically relevant. In 1 study of 247 men- 6 Illegal, Alien, and Other: Cultural Competency and Migration 97 tal health professionals across 32 states in the tions but then the second and third generations United States, the term “undocumented immi- catch up [8] grant” resulted in viewing vignettes more posi- Of course, there are a number of risk and resil- tively than “illegal alien” [3]. The language used ience factors, as well as cultural ones, that influ- to describe populations—including “illegal” and ence these epidemiological findings. Successful “alien”—can be profoundly marginalizing. migration may be a function of resilience but also This can produce stigma. Stigma has been increases exposures to risks; there may be noso- defined by Goffman as a “deeply discrediting” logic variations (how psychological distress and attribute that reduces the bearer “from a whole psychiatric illness presents) that make the pre- and usual person to a tainted, discounted one” sentation of psychological suffering more appar- [16]. Without a doubt, stigma is attached to ent to local cultures in more-assimilated later migration and migrants as bearers of disease, as generations, which may also be described as leeches and parasites on the economy, even nosologic visibility (as migrants acculturate, the though migrants benefit the economy [14], or as presentations become more apparent and cultur- criminals, even though they do not disproportionally congruent with those of the host country). ately contribute to criminality [17]. Sensitivity to the way in which mental illness Stigma, of course, operates within migrant is conceived is of course necessary. Behaviors communities as well, and there have been claims that may not seem normative or pathological in that there is a higher prevalence of stigma around one country (particularly around psychoses, hal- physical and mental health in immigrant popula- lucinations, ideas of references, visions, etc.) tions [10, 12, 26] which results in suboptimal may not be conceived in the same way in care [20, 43]. However, this is not necessarily another—and certainly some behaviors may be true or at least universally true (as when Nadeem considered pathological by migrant parents but et al. show that immigrant Latinas were most normative in their new country (such as with likely to want mental health care and were among some forms of teen rebellion or sexual or gender the most likely to report stigma [22]), and it can expression). be a lazy assumption when much more subtle While it is important to get a sense of under- barriers are present, which are being called standing the cultural context for any diagnosis or “stigma” (e.g., the refusal to see a psychiatrist symptoms, cultural competency with migrant pop- may not be “stigma” per se but a lack of clarity ulations includes not forgetting the basics, such as about the role of this new physician). investigating how the person believes symptom onset is or is not linked to psychosocial stressors, ascertaining normative expectations around stress- Pathology ors, and being open to normative, cultural, and familial understandings of what is happening, as In terms of addressing mental health, there are well as providing supportive psychoeducation. longstanding debates in the literature about the Understanding cultural beliefs around health, relationship of migration to mental health, with illness, and treatment, and what resources are a substantial number of studies suggesting lower being used in the community (including reme- rates of mental illness in migrant populations, dies, medications, herbs, etc.) remains important, where migrants are doing better than native- but, as with all such discussions, should not lead born populations. The current evidence suggests to closure or assumption, such as assuming that that while immigrants tend to have lower rates there is an opposition between “traditional” ser- of mental illness in general, there is worsening vices and host nation treatment options. In one mental health in later generations [34, 42]. US study, for example, in Cambodian refugees in the studies that focus on anxiety, mood, and sub- United States, use of alternative and complemen- stance disorders, for example, suggest that tary medicine was positively associated with an immigrants tend to do better than native popula- increased use of “Western” providers [6]. 98 S. W. Henderson

Parenting experiences of migration lie across these generational tensions: immigrant parents are too over- Migration is a family affair, and whether the cli- worked, tired, and struggling with their own nician is encountering a child, a middle-aged psychosocial turmoil to the extent that they can- migrant, or a geriatric migrant, a family history not pay attention to their child’s distress…the should be obtained to understand who they are early experiences of biculturalism become trau- living with, and in considering cultural compe- matic and intensify ordinary developmental con- tency around migration, one has to be sensitive to flicts, setting up a vicious circle whereby problems family constructs and expectations. One of the at school and problems at home begin to com- key challenges for migrants in their families is pound each other [2]. around parenting. When it comes to parenting, once again, one Parenting is a function of cultural, social, and must remember the basics: what stresses parents biological imperatives, in which the parent not and children across the globe are very similar: only provides such basic needs as love, nutrition, youth want to grow up and be independent; par- shelter, and guidance, but introduces and instills ents worry about safety and values. Generational language, values, cultural norms, and beliefs, all factors that may influence mental health in chil- of which have their own origins in earlier homes, dren and families include cultural and personal places, and societies; and yet, of course, as the beliefs around success, about parental “sacrifice” expression goes, it takes a village to raise a child, on behalf of their children, educational expecta- and children have their basic and developmental tions in the household, as well as the multitude of needs met by more than just their parents, learn- beliefs around socialization, especially regarding ing from peers and other adults around them. For sexual and gender identity development, that a migrant parent, this will almost certainly mean almost universally can create conflict in homes greater exposure to host country youth culture for but may be more pronounced in immigrant their children. While such a statement is hardly households [32]. controversial, and while it is recognized that In order to elucidate the potential conflicts in there are intense social and political pressures the family, and to get to understand what the par- that arise with migration and that affect parent- ents are experiencing, the clinician can ask opening, this simple observation opens up genera- ended questions about how the parents themselves tional schisms that, while they always exist, can were raised, how they want to raise their own be specific to migrant families. Not to put too fine children, what sort of differences they see a point on it: children are socially and culturally between their own parenting and parenting in different from their parents, and these differences non-migrant communities they live among, and can be magnified by migration [41]. what expectations they have for behavior, roles, The consequences of this for mental health and future goals for their children (and how these can be enormous and require sensitivity to differ- might be different from their country of origin). ences, without necessarily assuming what those It is often, although by no means always true, differences are. For example, the assumption that that children assimilate more rapidly into the host an immigrant parent’s values are necessarily the country, which can result in “acculturative family same as those that are assumed to derive from distancing” (acculturative gaps between genera- their point of origin can be a mistake (e.g., one tions), which in turn can create stress, as well as might assume that the parent would believe in the potentially different expressions of symptomol- same gender roles commonly thought to be prev- ogy in mental health, reducing the ability of gen- alent in his or her country of origin, when in fact erations to understand each other’s psychological that parent left the country of origin in part suffering [19]. because of those roles). These concerns can also be addressed with Furthermore, as psychiatrist (and immigrant), open-ended questions about hopes and concerns Salman Akhtar, points out, the parents’ own the parent might have (about how the child is 6 Illegal, Alien, and Other: Cultural Competency and Migration 99 adapting to the new culture, how it is affecting of any particular culture [11]. One author their relationship, about how they would like describes a naturalization ceremony where new their children to be connected—or not—to the immigrants are becoming US citizens, which parent’s country of origin, and what sort of prac- touches on all these models, and how the tices and beliefs from the home country). It is woman presiding over the ceremony said that important not to avoid issues that are commonly the new citizens “should speak English when- found in generational conflicts and directly relat- ever they could, take part in elections and oth- ing these to questions about the parents’ own erwise fulfill their civic responsibilities, but experiences and history, such as around gender she also told them they should feel free to con- roles, romantic relationships, and expectations tinue speaking their native language, celebrate around autonomy, and schooling/employment. their own cultural backgrounds, and stay true In addition, beliefs around parenting may to their religions” [15]. clash with local beliefs—as may happen with While there are many possible ways in which corporal punishment. This can result not only in any cross-cultural encounter can take place, stress within the home but may result in severe migrants will negotiate these tensions between legal consequences. Assessing for how children exclusion and assimilation, alienation and are punished and providing culturally sound acculturation, and the extent to which they can guidance on how to deliver rewards and conse- engage in biculturality on a personal level; quences may prevent severe legal consequences within families, however, there may be different or removal from the home. ways of resolving these tensions, including across generations [44, 45]. The clinician must not only be attuned to these differences, but What Do We Expect? aware that bicultural stress may affect generations differently, as well as having different There is often intense political debate around impacts on mental health [31]. In addition to how migrants should adapt to their host country assessing integration, assimilation, and bicultur- with frank and often dissonant expectations for alism, there may also be those who find they fit migrants. These conflicts can also play out within in nowhere. In 1 study of over 3000 adult sec- migrant communities. Three common models ond-generation immigrants in Canada, Berry conceptualize this process of adaptation and and Hoo identified a “marginalized” population speak to the challenges faced by migrants. who had a weak sense of belonging both to Assimilation, one model for adaptation, has Canada and their ethnic group [5]. been defined as the process by which “the culture of origin is rejected and the host culture largely adopted, with the loss of language and customs Loving the Alien of origin” [29], whereas acculturation, a second model, is a process of immersing oneself into the Cultural competency in addressing the issue of host country without the full loss of language and immigration requires an awareness that anti- customs, often with a goal of “biculturality” in immigrant sentiment and anti-immigrant policies which the person remains part of one’s culture of will affect how, when, and why immigrants will origin but can function in and participate in the access and make use of mental health services; a host culture. Of course, this cannot be easily dis- comprehensive approach to cultural competency tinguished from political and ideological assimi- beyond sensitivity in the individual encounter is lation or acculturation. ensuring that the space and environment is safe and Other models include “fusion” (in which supportive, from having appropriate translation and cultures blend to form a third, new culture) and interpretation services to sensitivity around how multiculturalism, in which there is a co-exis- and when documentation of any nature is requested tence and sharing of cultures without the loss (including personal identification). 100 S. W. Henderson

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Carl Bell and Christine M. Crawford

Introduction vides a description of the history, context, and dynamics that influence the mental health and People of African Descent (PAD) in the USA are wellness of PAD in the USA. The authors also comprised of both African Americans—many of identify and delineate treatment needs, suggest whom have marched a rough terrain, from roots ways to address these needs, delineate gaps in Africa to crossing the ocean to the USA, expe- within the system, and provide recommendations riencing enslavement and for some, to present- for next steps. Ideally, after reading this chapter, day mass incarceration—and more recent African readers will have taken one step forward along and Caribbean immigrants. For some African their path to better the mental health treatment of Americans, the path through American slavery African Americans and have an idea of directions has led many to exposure of significant collective for future learning and growth. Unfortunately, and personal trauma that deeply influences their our information about the recent PAD immigrants mental and physical health. For other PAD who is just beginning to be unearthed, so we will need had voluntarily immigrated to the USA, the path to be patient until we can speak more confiden- has been one of historical colonialism, national tially about these populations’ issues. independence, and recent immigration. In order to effectively treat and even prevent mental disorders in PAD, it is important to know and appreci- Who Are People of African Descent ate the history, context, and dynamics that in the USA? influence this diverse group of people. Without this knowledge and subsequent deliberate In the USA, PAD constitute approximately 13% responses, the mental and emotional strife that of the population with over 42 million people [1]. some PAD face will persist. This chapter pro- Who these people are is a complex question with a multilayered, multifarious answer. This ques- C. Bell (*) tion can be answered on various levels—from Medical-Surgical/Psychiatric Inpatient Unit, Jackson history and collective experiences to behavioral Park Hospital, Chicago, IL, USA characteristics, values, norms, and demograph- University of Illinois at Chicago, Chicago, IL, USA ics. On the surface, the whole of PAD is defined C. M. Crawford in the title—those who have roots in Africa who Department of Psychiatry, Massachusetts General live in the USA. However, identity goes much Hospital, Boston, MA, USA deeper than the location of a person’s or group’s Harvard Medical School, Boston, MA, USA roots. Although PAD have ancestry from the

© Springer Nature Switzerland AG 2019 105 R. Parekh, N.-H. T. Trinh (eds.), The Massachusetts General Hospital Textbook on Diversity and Cultural Sensitivity in Mental Health, Current Clinical Psychiatry, https://doi.org/10.1007/978-3-030-20174-6_7 106 C. Bell and C. M. Crawford same continent, the cultures and ethnicities on enslaved. For example, in 1851, Samuel this land mass are quite varied. In addition, com- A. Cartwright proposed two slave-specific disor- ing from Africa, people of the African Diaspora ders: drapetomania and dysaesthesia aethiopica. were taken to various parts of the world, includ- Drapetomania was deemed a “disorder” charac- ing countries ranging from Haiti to Brazil to the terized by slaves running away and seeking free- USA. Africans were sold directly from African dom. Cartwright proclaimed that equal treatment countries, particularly West Africa, and taken to was the cause and enforcing submissiveness was the USA to be used and/or sold again. Progeny treatment. In order to prevent the disorder, own- who stayed in the USA are now typically catego- ers were prescribed to treat the enslaved like chil- rized as African Americans. However, over the dren [3]. Laziness characterized dysaesthesia years, the variety within PAD has increased with aethiopica, which was supposedly related to skin the immigration of Blacks from the Caribbean, insensitivity. Thus, treatment included stimulat- South America, and directly from Africa. Over ing the skin by washing, covering it with oil, 91% of PAD are native born Americans; 9.1% are slapping it with a leather strap, and working in immigrants; 4.9% of those are naturalized citi- the sun [3]. Enslaved individuals were not only zens, and 4.1% are not yet a citizen of the USA used as “workhorses,” but physicians bought and [1]. Additionally, Africans had the fastest grow- also used them as participants in dangerous med- ing segment of the black immigrant population in ical experiments that were seen as not safe the USA, increasing by 137% from 2000 to 2013. enough for European Americans. In surgeries, Approximately 28% of African immigrants came the enslaved were deprived of anesthesia and to the USA as refugees [2]. Thus, there are mul- were often given subpar medical treatment. tiple histories, contexts, and cultures within this Following slavery, medical (both physical and group. Whether bought and sold by the USA, mental) injustices persisted, such as the depriva- British, or French, slavery occurred in the tion of proper psychological treatment for African Caribbean, Europe, USA, and other places. Americans. Historically, there were few psychi- However, the vitriolic nature of the slavery was atric facilities that treated African Americans different from place to place. Thus, a great major- with legitimate mental illnesses [4]. ity of PAD have connections to US enslavement In the decades following African enslavement, and have experienced collective and historic governmental institutions such as public health trauma. Throughout this chapter, the authors go services and schools and public policies have left deeper into the aforementioned layers of the these communities disproportionately poor [5] identity and culture of PAD, but will focus on the and unhealthy [6]. As in the other sectors of the majority of PAD—African Americans. This USA, in mental health, African Americans were chapter also includes the mental health repercus- seen as inferior to European Americans and, thus, sions (and even deliberate consequences) of some much of their research and diagnoses were tainted of these collective and historical experiences. by confirmatory bias and reflected this notion. Eugenics and similar research, ideology, and general ethnocentric monoculturalism [7] reigned History As It Relates to Mental and were perceived as truth [8]. Thus, psychia- Health trists and psychologists viewed African Americans unable to experience “sophisticated” From enslavement to the present day “post- disorders that required some abstract thought, racial” society, African Americans have had a such as depression [9]. Thinking such as this has tumultuous past relationship with health services contributed to significant, generational misdiag- in the USA. Hence, it has led many to have a mis- nosis, leading to mistreatment and poor progno- trust of health services, including mental health. ses. In the area of public health services, the During times of enslavement, diagnosis was used Tuskegee experiment is one example of a quint- to manipulate and control those who were essential ethical crime that left African Americans 7 Psychiatry for People of African Descent in the USA 107 distrustful of the system. Beginning in 1932, the and lack of access [6], African Americans use US Public Health Service (PHS) in Alabama mental health services less than European began an investigation of how syphilis influenced Americans. the physiology of the body, particularly among African American men. While their participants were alive, their study was mere observation, Prevalence and Utilization watching the progression of the disease until death. Once they died, the physicians performed African Americans face many issues that nega- autopsies to better study the bacteria. “… These tively affect their mental health and general well- men were regarded by an impatient PHS as living being, including disproportionate amounts of cadavers, more valuable to American medicine as poverty, low-quality education [17], racism [18], dead than alive” [4]. Although their study was being unfairly targeted by the criminal justice sys- disguised as treatment, PHS’s intentions were tem [19], and cloistered in ghettos [20]. never to provide treatment but to catalogue the Paradoxically, most rates of mental disorders and dying process and dissect at death. In their mental illness in African Americans are less or recruitment of participants, they “offered” treat- equal to European Americans. Although it has been ment. Throughout the study, they pretended to well documented that suicide rates are generally provide treatment, giving vitamins and insuffi- higher for European Americans when compared to cient doses of medication. Even when penicillin Africans Americans, recent data demonstrated an was introduced as an “effective drug” for syphi- increase in the rates of suicide in African American lis, the physicians continued their study and their children aged 5–12 years. During 2001 through deception. The study was maintained despite the 2015, African Americans aged 5–17 years had a availability of treatment until 1972. Over the 42% lower rate of suicide than European American course of this study, over 100 African American youths. However, when the data was stratified for men died, 40 of their wives contracted the dis- age, African American suicide rates in this age ease, and nearly 20 children were infected at group during this time period went up from 1.36 birth [4]. Hence, there is, for some, still a trans- per million to 2.54 per million compared to 1.14 ferred, generational, and disproportionate mis- per million to 0.77 in European American children trust of the healthcare system. [21]. Although this finding suggests that African After the 1970s and with the more significant American children younger than 13 had a two shifts due to the civil rights movement, health- times higher rate of suicide when compared to care, including mental health, opened up to European American children, the clinical signifi- African Americans. However, as overt racism did cance is currently up for debate given the small dif- not align with American ideals, more subtle ference between 1.36/1,000,000 compared to forms of racism began to manifest. In seminal 2.54/1,000,000,00 [22]. research, Dr. Pierce [10] started to identify more For African Americans over 50 years of age, subtle racial dynamics, such as microinsults and 8.8% reported an episode of major depressive dis- microaggressions, which continue today [11]. In order (MDD) in their lifetime and 4% in the last the 1980s, this nation entered the era of cultural 12 months. For older Black Caribbeans, 11.2% sensitivity, with calls for more social workers, reported MDD in their lifetime and 8.2% in the physicians, psychologists, nurses, and psychia- last 12 months [23]. In this case, Black Caribbeans trists of Color [12] and a greater focus on diver- had a higher prevalence rate than White Americans sity issues. Also during this time, misdiagnoses (5.9%) of MDD in the last 12 months. Outside of of African Americans were identified as a major that, older White Americans had higher rates of problem [13, 14], which also continues today MDD [23]. Such is the case for most other mental [15]. Thus, some of the numbers around preva- illnesses (see Table 7.1), except for more stigma- lence are thought to be inaccurate [16]. Today, tizing disorders like psychotic disorders and per- due to the mistrust, mistreatment, stigma [4, 16], sonality disorders [24]. 108 C. Bell and C. M. Crawford

Table 7.1 Mental illness in PAD African Caribbean European Mental illnessa Americans (%) Americans (%) Americans (%) 12-month prevalence of any mood disorder 7.75 4.82 8.63 12-month prevalence of any major depressive disorder (MAD) 4.58 2.22 5.53 Lifetime suicide ideation and attemptsb Ideation 11.7 12.3 Attempt 4 5.1 12-month prevalence of any anxiety disorder 10.72 6.22 11.70 12-month prevalence of any substance use disorders (SUDs) 16.63 4.56 20.44 12-month prevalence of any psychotic disorder 0.58 0.61 0.32 12-month prevalence of any personality disorder 16.67 16.79 14.65 Lifetime prevalence of conduct disorder 1.05 0.97 0.99 Lifetime prevalence of any disorder Axis I 43.4 24 55.4 Axis II 16.8 16.7 14.7 12-month prevalence of any Axis I disorder 28.1 14.5 31.5 aAll data except on suicide is from Gibbs et al. [24] bData from Joe et al. [25]

Adverse Childhood Experiences ease, 2.4 times more likely to suffer from a stroke, 1.6 times more likely to have diabetes, and 1.6 Adverse childhood experiences (ACEs) are expo- times more likely to struggle with severe obesity sures in childhood (prior to age 18 years old) that than those patients with zero ACEs [27]. In their are deeply distressing or disturbing. Felitti and studies with the Center for Disease Control and Anda [26] have conducted studies assessing the Prevention [28], they found ACE disparities by number of people’s ACEs (ACE score) and their race and SES. There was an inverse relationship correlation to health-related problems in adult- with SES and ACE score. Ironically (given the hood. They found that the higher number of disparities in education and income level) [17], ACEs, the more likely the person is to experience compared to Whites and Hispanics, African later morbidity, such as cardiovascular disease, Americans have the lowest percentage of those diabetes, substance use disorders (SUDs), can- who had experienced five or more ACEs. cers, and sexually transmitted diseases. Those However, they are more likely than Whites to with 4 or more ACEs were 7.4 times more likely have four ACES, and they have the highest preva- to abuse alcohol, 10.3 times more likely to abuse lence of family fracture (parental separation/ drugs, 4.6 times more likely to have depression, divorce) and having a household member in 12 times more likely to have SA, 2.2 times more prison [28]. Other confounding variables include likely to be a smoker, and 3.2 times more likely to the fact that there is a disproportionate represen- have over 50 sexual intercourse partners than tation of African Americans in special education, people with zero ACEs. Those with 4 or more foster care, and the criminal justice system. ACES were 2.2 times more likely to have isch- Combined, these facts make the depiction of emic heart disease, 1.9 times more likely to have African American people and their ACE score cancer, 3.9 times more likely to have chronic seem incomplete. One fact that may complete the lung disease (bronchitis and emphysema), 1.6 picture is what is constituted as trauma. The ACE times more likely to have skeletal fractures, 2.4 assessment does not include racism, witnessing times more likely to have liver disease, 2.5 times violence in the community, or being unfairly tar- more likely to have a sexually transmitted dis- geted by the criminal justice system [29]. 7 Psychiatry for People of African Descent in the USA 109

Factors Contributing row, and engaging in sex to escape their stress. to the Paradoxical Prevalence Rates Thus, we see the tremendous historic and present stressors, the lower rates of diagnosed mental dis- There is apparent irony when examining the prev- orders, and high rates of physical illness (e.g., car- alence rates of mental disorders and the predica- diovascular disease and diabetes). Another ment of many African Americans and some explanation for the lower rates of diagnosed men- possible reasons that may explain this seeming tal disorders is the finding that African Americans paradox. Harken back to the history of not think- do better when assessed with measures of flour- ing that African Americans were sophisticated ishing [32]. This discovery may indicate that enough to have a mood disorder [9] and the use of many African Americans may have significant diagnoses to maintain status quo. Such could resilience and protective factors buffering them explain the higher rates of psychotic disorders (or against the some of the ill effects of hardship. diagnoses should we say) and lower rates of mood disorders. Furthermore, the paradox of historic and collective hardship and lower rates of general Utilization mental disorders can also be understood within the context of a lack of cultural sensitivity and Another possible explanation for this seeming knowledge and, thus, misdiagnosis. Culture- contradiction is the rate of mental health services bound syndromes and certain culturally specific utilization. Across the board, African Americans idioms of distress, expounded on later in this use mental health services less than Whites. chapter, could convolute psychological case con- According to data from the National Comorbidity ceptualization and lead to misdiagnosis. If mental Survey–Adolescent Supplement, Costello and health professionals are not aware of certain colleagues [33] found that African Americans symptoms within culture-bound syndrome cate- adolescents ages 13–17 years old were signifi- gories, they may diagnose it as something else cantly less likely than their White counterparts to [30] or may not diagnose it at all. Furthermore, utilize specialty mental health or general medical African Americans suffering from ailments may services for mental health disorders. distrust the system or professional and choose not For college students, Hunt et al. [34] identified to disclose their experience. If they do disclose significant mental healthcare disparities between some type of psychiatric-related symptom, it may Whites and their minority counterparts despite be more likely that they disclose a physical or having access to mental health services on their somatic symptom. Hunter and Schmidt [16] sug- respective college campuses. According to data on gest that some of the physical symptoms African college aged adults between 18 to 25 years old Americans disclose, usually going along with car- from the National Survey on Drug Use and Health diovascular disease, diabetes, and hypertension, [35], 14.1% of Whites used mental health services are actually “somatizations” of anxiety. Jackson in the past year compared with 6.5% of African et al. [31] propose that the physical symptoms are Americans, 5.7% of Asians, and 6.7% of Hispanics. a result of what Wright [32] calls “soft addic- This disparity in mental healthcare utilization tions.” Soft addictions are distractions or ill meth- persists all throughout adulthood. Adults of two or ods used to escape our more challenging emotions more races are more likely to utilize mental health and directly addressing our pain, including activi- services when compared to Whites and African ties like watching television and eating junk food. Americans. Approximately 17.1% of adults of Jackson and his colleagues [31] convey that many two or more races accessed mental health services PAD, especially in low-income communities, between 2008 and 2012 versus 16.6% of White may be eating their pain, drinking away their sor- adults and 8.6% of African Americans [35]. 110 C. Bell and C. M. Crawford

Additionally data have demonstrated stark dif- of low-income African American women ferences among those of different ethnic back- addicted to cocaine in New York City had been grounds in the rate of prescription drug use for sexually assaulted before they began abusing those with a psychiatric condition. Prescription drugs. Related to the notion that SUDs are an drug use was the highest among Whites with idiom of distress in low-income African 14.4%, American Indian/Alaska Native 13.6%, American men, Bell et al. [39] identified a phe- and African Americans 6.5%. In regard to seek- nomenon of chronic alcoholic hallucinosis. ing out care in an outpatient setting, only 4.7% of These patients had extensive work histories and African Americans received care in an outpatient sophisticated interpersonal skills, but reported setting between 2008 and 2012 compared to hallucinations, insomnia, and paranoid ideation 7.8% of Whites [35]. without psychosocial deterioration. Furthermore, Numerous factors contributing to the dispari- these patients did not develop their psychotic ties in mental healthcare utilization have been symptoms until they were mid- or late-life adults studied by various researchers; however, the reli- after an extensive history of chronic substance gious beliefs of some African Americans have abuse. Alcohol consumption is often a “poor per- been found to influence the likelihood of receiv- son’s vacation.” Unfortunately, it can be fatal if ing formal mental healthcare [36]. Historically, abused chronically, as cirrhosis was identified as African Americans have high levels of religiosity one of the six causes of excess deaths in African and typically seek out guidance on mental health- Americans [40]. Social drinking by African related issues from clergy as opposed to formal American women who are unaware they are mental health specialists [36]. Lukachko and her pregnant is also responsible for the high rates of colleagues found an inverse relationship between fetal alcohol spectrum disorders in African church attendance and the use of formal mental Americans [41]. health specialists. She found that African Another common idiom of distress in PAD is Americans who reported a high degree of religi- spiritual pursuit. The use of religion is a mainstay osity were less likely to utilize mental health proof PAD’s quest to respond to stress, distress, and fessionals when compared to African Americans traumatic stress in a healthy manner [42, 43]. The with low levels of religiosity [36]. research is clear that PAD who are experiencing serious distress are particularly prone to use religious coping strategies and more likely to seek Idioms of Distress help from a minister than other helping professions [44]. A lack of mental health service utilization may perpetuate problems, such as idioms of distress. Idioms of distress are ways that people cope, be it Culture-Bound Syndromes in PAD constructive or destructive, with their pain or struggle. They are alternatives in the expression Culture-bound syndromes, unlike idioms of dis- of psychosocial distress and are often shaped by tress, are directly connected to rich indigenous situational sociological circumstances. traditions and are not necessarily a choice. They Accordingly, idioms of distress vary between are indigenous traditional ways for various cul- social classes. Thus, in addressing idioms, it is tural, racial, and ethnic groups to express psy- important for mental health providers to be aware chological distress and other forms of emotion of how demographic factors, like social class, [2, 45]. Researchers have demonstrated that the influence the idioms. symptoms reported in anthropological literature A common idiom of distress found in low- resemble those of certain established mental income African Americans is substance use dis- disorders, and that they often warrant and are orders (SUDs). Fullilove et al. [37, 38] provide linked to seeking assistance among African evidence of this by noting a substantial percent Americans [46]. 7 Psychiatry for People of African Descent in the USA 111

Acute hallucinatory phenomena known as be most potent, treatment should be culturally “bouffees delirantes,” a characteristic feature of sensitive. There are four key goals in the assess- West African Psychiatry [47], is an example of a ment, treatment, and cultivation of mental well- culture-bound syndrome. From a study of 125 ness in African Americans. First, it is critical to cases observed in Fann Dakar, Senegal, over a dispel racial stereotypes and myths within the period of 14 months, Collomb [48, 49] estimated mental health provider. Second, there is a need to that the incidence of such episodes, compared to address the significance of the culture. Third, the other “functional” psychoses, is about 30%. The health professional should be sensitive to the psychotic episodes are characterized by a sudden, patient’s needs and reality (i.e., their biologic, explosive episode, which have a short course. emotional, intellectual, spiritual, social, and con- They are more likely to occur when there is some textual reality). Finally, it is important to discuss change in relationship or in the environment and adjust for their expectations. Culturally sen- (e.g., when a person is called upon, owing to out- sitive (or responsive or humble) treatment can side pressure, to play a part other than a familiar ensure these goals are met. role) [49]. Another proposed culture-bound syndrome is isolated sleep paralysis (also known as “the witch Cultural Competence is riding you” or “the haint is on you”), a state experienced while awaking or falling asleep and Cultural competence is the ability to effectively characterized by an inability to move although interact with others regardless of cultural back- being wide awake [30, 50]. This syndrome was grounds while being “respectful and responsive found to have occurred at least once in 41% of to the health beliefs, practices, cultural and lin- 108 African Americans participants composed of guistic needs of diverse population groups” [54]. 36 controls (nonmentally ill people), 36 precare The term culture encapsulates other characteris- participants (nonpsychotic, anxious patients who tics besides race and ethnicity including age, gen- had never been psychiatrically hospitalized), and der, sexual orientation, disability, religion, 36 aftercare participants (psychotic patients who income level, education, geographical location, had previously been hospitalized for psychotic and profession [54]. The phrase cultural compe- illness) [30]. It was later discovered that a recur- tence can be misleading, as the term “compe- rent pattern (one or more episodes per month) of tence” seems to connote an end, as if one could isolated sleep paralysis in African Americans was declare oneself competent. However, our use of described by at least 25% of the afflicted study competence refers to a journey or process of participants [50]. In this study, frequent episodes becoming. This is why the word “competence” were associated with stress, and participants with could be interchanged with responsiveness, sen- isolated sleep paralysis had an unusually high sitivity, or humility. Cultural competence encom- prevalence of panic disorder (15.5%). These passes a set of skills necessary to build strong results have been replicated by several other working alliances across cultures. It includes research groups [51–53]; thus, it has now been awareness, knowledge, and skills [55, 56]. The firmly established as a culture-bound syndrome first component encompasses awareness of our in African Americans. own biases and knowledge that our biases (both tacit and known) can affect our communication with others. It also includes awareness that each Treating People of African Descent one of us has cultural influences and those influ- in the USA ences vary depending on person and context. Knowledge includes knowing about our own cul- Regardless of distress or syndrome, treatment tural influences and those of the people with can significantly help in reducing or even allevi- whom we work. This includes history, context, ating distress and disorder. However, in order to and cultural facets and how these variables 112 C. Bell and C. M. Crawford influence behavior [56]. Skills refer to the abil- This natural and, most of the time, protective pro- ity to practice efficaciously one’s profession cess [63] can become destructive to others when with the knowledge of culture. These skills applied to people. Due to the social atmosphere in could include assessment, diagnosis, treatment, which Americans live, we are repeatedly exposed and self-development. For example, there are to stereotypes about groups of people (e.g., certain cultures where family is of central impor- Muslims are terrorists, African Americans are ath- tance, the main support system. Therefore, it may letic, women are bad at math). Even if a person be best for the patient/client’s progress if the fam- purports to not be racist, sexist, or classist, their ily were included in assessment and treatment implicit beliefs are infused with these concepts [57]. Other skills include emotional intelligence, [63, 64], and, therefore, affect expression, interac- social intelligence, and cognitive skills, all of tion, decisions, and behaviors [65, 66]. Lewis which help to enhance awareness and manifest et al. [67] conducted a study finding that, when strong relationships and working alliances [29]. presented with a case vignette where the race in If a professional is not moving forward on this the vignette was artificially altered to be either continuum, there are potential dire consequences. Afro-Caribbean or White, 63% of British psychi- A patient’s life may be at stake if that person does atrists perceived the Afro-Caribbean case to be not understand or accept life-saving information. more violent and more criminal. They were more There are myriad preventable diseases and risky likely to diagnose the Black person with a canna- behaviors. With the right message given in the bis psychosis and acute reactive psychosis than a right way, many of those diseases will actually be disorder not associated with illegal drug use. prevented [58]. For example, Coles et al. [59] Confounding this stereotype phenomenon is the have shown that vitamins and mineral supple- seemingly biologically based in-group/out-group ments given during pregnancy can reduce the bias [68]. Studies have shown that we have a neu- negative outcomes of fetal alcohol exposure; rological preference for our own group and lack of however, such an intervention would need to be empathy for out-groups [66, 69, 70]. For example, culturally competent to get traction, especially in Xu et al. [69] found that when a racial group looks PAD where the problem may be greater [60]. at pictures of people in their own group experienc- Based on studying CHRNA7 (the a7-nicotinic ing physical pain, their anterior cingulate cortex acetylcholine receptor gene), Freedman’s team at (ACC) activates. However, when looking at pic- the University of Colorado have evidence that tures of members of a racial out-group experienc- giving pregnant women phosphatidylcholine ing pain, ACC activity dramatically diminishes. In may prevent schizophrenia, autism, and attention other words, empathy was reduced to near null for deficit hyperactivity disorder [61]. Thus, cultural racial out-groups. Fortunately, there is evidence sensitivity is not only advised but it also should that rectification is possible. be required for those in the helping professions. Firat and colleagues expanded upon previous Cultural sensitivity would preclude inadvertent research on neurobiological responses to racial microinsults from being ignorant of African out-groups by examining how the brain responds American culture. to racial out-groups in positively valued social positions versus less valued social positions [71]. Participants were instructed to look at a series of Awareness: Know Thy Self pictures of people, animals, and objects. The pictures of people were either African American or Since human behavior is theoretically caused by White and were depicted wearing certain cloth- the influences of biology, personality, and famil- ing and accessories as well as participating in ial, sociological, and cultural contexts [62], it is activities that would be reflective of those com- multi-determined and complex. Neurological monly associated with lower-class, middle-class, automaticity adds to this complexity of human and upper-class status. The participants were behavior and leads to automatic stereotyping. then asked to identify one of eight emotions that 7 Psychiatry for People of African Descent in the USA 113 were elicited from the picture. The results indi- been staples in the Black community, including cated that the participants identified more posi- religion/spirituality, extended family, and racial tively related emotions to White middle-class socialization. There are also core cultural vari- people than middle-class African Americans. ables, including class and acculturation that Researchers also performed the same experiment deeply influence behavior and can affect percep- with an fMRI and found that there was greater tion of treatment. Regarding context and regard- ventromedial prefrontal cortex (vmPFC) activa- less of decades passing since the Civil Rights Act tion while viewing pictures of White middle- in 1964, mental health professionals should be class people when compared to African American aware that many African Americans continue to middle-class people. This finding further pro- face significant interpersonal and institutional vides evidence that the vmPFC’s role for racial racism [73]. evaluations is largely confined to the more positively valued and prized groups through regulat- Religion/Spirituality Religion and the Black ing positively related emotions [71]. Additionally church have been central protective factors in the researchers found that there was lower right history of PAD and continue to be noted as inte- amygdala activation for White lower-class indi- gral when working with the Black community. viduals compared to African American individu- Historically, the Black church built schools and als which is consistent with previous findings that served a strong political role, progressing civil the amygdala plays a role in racial evaluations rights and creating group solidarity. Although particularly for out-group class conditions [71]. this institution is not as strong as it once was, it Being aware of our context and, how context continues to be a major protective factor and has influences human thinking, including each men- much potential for uplifting the current commu- tal health professional, is vital to effective mental nity [74]. African Americans report more church health treatment with African Americans and attendance and prayer [75, 76]. These institu- other marginalized groups. If professionals are tions have been shown to help prevent risky not aware of what is “in the water we’re swim- behavior in youth [77, 78] and act as an exten- ming in,” we are likely to “spit something out” sion of one’s family. African Americans report that can harm a patient/client. Microaggressions being more likely to get support from their are examples of ways professionals can inadver- church or a religious institution than mental tently offend a patient/client. They are uninten- health professionals [34]. tional slights against a person because of their group [72]. For example, if someone walks into a store, sees a Hispanic customer, and asks where Extended Family For African Americans, to find the milk aisle, he/she may have committed extended family is another cultural protective a microaggression by assuming that the person factor, as it transcends the physical ties of blood. works at the store. Again, microaggressions may Friends, religious members, and neighbors are often be unintentional and go unnoticed by the considered family, equivalent to aunts, uncles, offender. It can be detrimental to the relationship and cousins [79]. Despite the disruption of the with a patient if these are done repeatedly and nuclear family in the Black community [28], without awareness [11]. extended family has served a vital role in caring for children, supporting mothers, and serving as role models [80]. Extended family has also been Knowledge: Know the Culture cited as important for supporting family mem- and Context bers in their health and preventing fatal diseases and mental health illnesses [81]. This type of As stated previously, the culture of PAD is quite family can act as a community and, thus, potent diverse and multifaceted. However, there are protective factor, surrounding and supporting the some core cultural-historical factors that have child, family, or adults. 114 C. Bell and C. M. Crawford

Racial Socialization and Acculturation Racial delineated by roles or gender. Education, work, socialization is central in identity development success, and self-reliance are highly valued. [82]. Positive racial socialization is imperative to Families are usually made up of two parents and counteract the myriad negative stereotypes of two kids. Parents usually own a home (perceived African Americans present in US culture and as a mark of success), are achievement oriented, established systems to reinforce them (e.g., crim- and upwardly mobile. They are also active in at inal justice system [19]). When manifested in the least one social organization and in community home, youth have been shown to do better in affairs. Most of the picture for middle-class Black school, regulate their behavior, and have higher families is quite similar to the traditional family self-esteem [83]. values and structure in the USA. Belgrave and Allison [86] note that, in many of these cases, Considering that racial socialization is protec- Black individuals have adopted US values more tive of African American youth, it only makes than the average European American. Clearly, sense that anything that would erode such social- this reality does not conform to the negative ization would be a potential risk factor. Such is matriarchal stereotypes about African American the case with acculturation. In a large epidemio- families. Knowledge of these facts is useful to logic study Burnett-Zeigler et al. found “a sense prevent mental health professionals from micro- of pride, belonging, and attachment to one’s insulting their patients because of the profession- racial/ethnic group and participating in ethnic al’s negative stereotypes. behaviors may protect against psychopathology; Willie [85] found the life of working class alternatively, losing important aspects of one’s African Americans to be characterized by hard ethnic background through fewer opportunities work, little leisure time, struggle, and necessary to use one’s native language and socialize with interdependence. Parents are usually working people of their ethnic group may be a risk factor in positions requiring manual labor or are in for psychopathology” [84]. semiskilled positions (e.g., secretary, certified nurse). Many times, parents are literate and Family and Class A perpetual stereotype of most have completed school with some drop- African Americans is that they are poor, raised by ping out of high school. Some went on to col- a single parent, from matriarchal households lege or had some trade work training. The headed by unemployed women with several chil- power structure is patriarchal; however, roles dren. Ostensibly, this is not true for most African are often divided by gender with men deciding Americans. Additional truths should be high- about money, maintaining the house, and advis- lighted to help dispel such stereotypes. In semi- ing the boys. The women cook, clean, and nal work [85], Willie described major distinctions advise the girls. A mother, father, and around by class in the Black community. Over a 30-year four children usually constitute family. Family period, he had students conduct structured inter- is a source of pride and parents define good views with thousands of Black families. He found behavior for their children as them staying out that decision-making, power structure, areas of of trouble from the police. Religion is impor- employment, routine, values, religious activity, tant and these families tend to attend church parenting, and number of offspring varied by weekly. Approximately one-third had moved up class. from poverty or down from middle class. They tend to be good examples of self-reliance and He found that middle-class African Americans can be thought of as innovators as they are cre- are typically conformist [85]. Many middle-class ative in developing adaptations for survival. parents have dual employment and often in the Thus, Willie’s [85] seminal works provides public sector, such as post offices or public mental health professionals with counter ste- schools. The power structure is usually egalitar- reotypical concepts of working class African ian, and family functions are shared and not American families. 7 Psychiatry for People of African Descent in the USA 115

The life of low-income African American Racism “For the average black person, literally families is typically characterized by struggle, hundreds of racist incidents crash annually into mistrust, and tenuousness. Due to their financial his or her life” [16]. The old saying that “sticks hardship, they make necessary, clever, and some- and stones may break my bones but names will times foolish arrangements to survive. These never hurt me” is not accurate, as racism has been arrangements are often against conventional linked to hypertension and heightened levels of mores, such as living with extended family or cortisol [87, 88]. Pierce [89] equated the effects caring for foster children for pay. Due to these of racism to that of terrorism and disaster, assert- life challenges, they have learned to expect little ing that experiencing racism is essentially trau- and not trust. This mistrust includes society but matic. He conveyed that microaggressions it also pertains to romantic partners and, thus, impinge on a person’s space, time, energy, and marriage is less likely. If marriage does occur, it freedom of movement. When exposed to myriad is typically at an early age. Children are often offenses over time, the victim is likely to adopt a born out of wedlock, and family size includes defensive, apologetic, and/or deferential mental approximately six children. They love their chil- stance. dren but have difficulty understanding and effectively communicating with them. They Albeit two decades have passed since contraindicate following certain misbehavior Pierce’s assertion, these insults are still as prev- patterns, but these warnings are often ineffec- alent and pernicious [11]. Although some pur- tive, as there is little concentrated or concrete port that we live in a “post-racial society,” this effort at prevention. However, there usually perception is actually antithetical from the exists a strong sense of loyalty between mothers truth. Alexander [19] eloquently provides sig- and their youth and between siblings to face the nificant evidence that there is a “New Jim struggles. Circumstances are transitory and jobs, Crow,” and this perpetuation of structural rac- homes, communities, and romantic partners ism is in the form of mass incarceration. Black often change. Thus, they experience frequent and brown people, especially men, are unfairly disappointment. Unemployment is a constant targeted by police [90]. It is important for the and likely specter. Parental employment usually mental health professional to know the social takes the shape of unskilled labor, like house and structural barriers African Americans face cleaners or factory workers. Parents have usually for if this is ignored, there can be premature ter- dropped out of school and, thus, portray them- mination [91], and treatment will be ineffec- selves to their youth as failures. Idioms of dis- tive. Burkard and Knox [92] found that tress such as drinking, drugs, and gambling may professionals who adopt this post-racial society be more frequent to escape temporarily from the reality are less successful with their Black stress of this life. Community participation is patients/clients. Those who had a color-blind rare, and they have experienced recurring fail- racial perspective were likely to disregard their ures and disappointments. Many times, this leads Black patients’ contextual reality and, instead, to them treating society in kind—rejecting it. believe the patient to be lazy. They placed the Religion is a place of solace for some, but it has responsibility of solving the problem more been rejected for others. In short, they could be often on their Black patient/clients than their seen as rebels. Here in Willie’s [85] works, we White clients. This type of misconception and find the source of the negative stereotypes of the consequent conceptualization and treatment is African American family, but with a major damaging and perpetuates disparities. Due to important difference that minimizes the demoni- microaggressions such as these, “… racial and zation of the poor African American family, i.e., ethnic minorities bear a greater burden from the situational sociological context that makes it unmet mental health needs and thus suffer a necessary for poor African American families to greater loss to their overall health and produc- functions as many do. tivity” (p. i) [2]. 116 C. Bell and C. M. Crawford

Skills: Assessment, Diagnosis, when compared to Whites. A number of research- and Treatment ers have estimated that diagnoses of schizophrenia have been given twice as much to African The application of culturally competent clinical Americans than to Whites [103–107]. Strakowski skills which are sensitive to the unique qualities et al. [101] studied this dynamic and found that of African Americans is critical for reducing vari- African American men with affective disorders ous inequalities in service delivery and poor identified by expert consensus were significantly mental health outcomes [91–93]. Here, we focus more likely than other patients to be diagnosed on clinical skills, including diagnosis, assess- with a schizophrenia spectrum disorder by clini- ment, and treatment. cal assessment and structured interview. Some have argued that this focus on schizophrenia and

Assessment Due to the history for African other more stigmatizing diagnoses are due to Americas and the lack of studies that determine structural racism [13, 14, 97, 98]. A manifesta- norms and psychometric measures for African tion of this racism, and another form of microag- Americans [2], the assessment of PAD has been gression, is ignoring the history and contextual fraught with difficulties. An early example of this barriers of a group [11]. Bell, Jackson, and Bell can be found in Lauretta Bender’s work on [108] found that 28% of an African American “Behavior Problems in Negro Children” [94] outpatient community mental health clinic sam- where she noted that the two most distinguishing ple had historical issues with mental retardation, characteristics of “Negro” children were their special education, attention deficit/hyperactivity ability to dance and their capacity for laziness. In disorder (ADHD), autism, head injury, and/or a more recent publication, Adebimpe [95] points childhood trauma, which influenced assessment out that the Minnesota Multiphasic Personality and had to be taken into account for accurate Inventory (MMPI), widely used in psychiatric diagnosis and treatment. Thus, part of the skill of research and practice, is biased toward African culturally sensitive clinical diagnosis is integrat- Americans, who tend to obtain higher baseline ing the culture, context, personal, and family his- scores on a number of scales, including the tory into conceptualization. schizophrenic scale, which means African Americans are more likely to be misdiagnosed as schizophrenic. Unfortunately, this area of study Treatment Mental health treatment can take the continues to be disregarded [2]. form of psychotherapy, support groups, and psychopharmacology, among other forms; however, these three are highlighted here for African

Diagnosis There is quite a long history of misdi- Americans. agnosis of African American. Bell and Mehta [13, 14] began a series of research studies examining the misdiagnosis in African American Psychotherapy and Support Groups patients. They found that there was significant misdiagnosis of what was then called manic- As mentioned previously, there are four key goals depressive illness (bipolar disorder). Other stud- in treating African Americans [109]. Within psy- ies have corroborated this phenomenon of chotherapy, it is important that these are addressed misconceptualization in people of color [96– in the relationship between patient/client and 101]. West et al. [102] found that African therapist. First, the therapist must engage the American patients were more likely to receive a awareness of his/her own biases and explicitly diagnosis of a schizophrenia spectrum disorder confront his/her stereotypes of African or a non-alcohol SUDs compared with White Americans. This process should be done before patients. They were also less likely to receive a and throughout the relationship with patients of diagnosis of a depressive or anxiety disorder African descent. If this is not directly confronted, 7 Psychiatry for People of African Descent in the USA 117 microaggressions may occur or misdiagnosis activity of liver enzymes, a major determinant in may result. Microaggressions can offend patients/ pharmacokinetics, is determined genetically, clients and, hence, disrupt therapeutic rapport. although environmental factors can alter genetic Second, addressing the significance of the race of activity. Understanding the genetics and environ- the patient/client is critical. Although the evi- mental influences (e.g., use of medications, dence is limited, most White therapists avoid this drugs, diet) of different populations may help to conversation [110]; however, avoiding it does not predict side effects, blood levels, and potential void this underlying dynamic, and what is unsaid drug–drug interactions. can seep into other areas of the relationship. Although race is a sociologic construction and Third, it is important to be cognizant and appreci- not a biologic reality, there are some biological ate the patient’s/client’s needs and reality. As heritable differences between different ethnic stated previously, if context is not considered, the groups. Accordingly, while the biology of the therapist may misconceive the patient’s/client’s human race is essentially the same, there are psychodynamics and provide ill treatment. some cultural and ethnic differences and some Furthermore, critical needs may go unmet that differences in biological heritage that cause some are essential for improvement. Fourth, the thera- African Americans to be unique in their biologi- pist needs explicitly to discuss the patient’s cal makeup. These unique differences require expectations about therapy: what it will look like, consideration in the pharmacological treatment how it will end, what the process is, or expecta- in African Americans. Unfortunately, recruitment tions around possible results. Finally, throughout of African Americans in clinical trials has histori- treatment, from assessment to termination, there cally been low due to barriers such as mistrust, should be a focus on strengths. The clinician’s stigma, and competing demands [114]. As a ability to elicit and capitalize on the patient’s/cli- result, there is a poor understanding of similari- ent’s inherent strengths fosters a more collabora- ties and differences between various cultural, tive therapeutic relationship and allows the racial, and ethnic groups regarding their poten- patient/client to recognize that they are in posses- tially unique pharmacokinetics. Accordingly, sion of the tools to aid in their treatment and psychiatry is bereft in knowledge regarding recovery [111]. effectiveness, safety, and tolerability of psycho- Given the importance and potential support of pharmacology in African Americans. family, the use of multiple family groups has Fortunately, research and clinical practice been found effective in both treatment and pre- indicate that usually individual variation is more vention for African Americans [81]. Multiple substantial than cultural/ethnic variation. This family groups are constituted by different mem- reality makes it dangerous to simply make stereo- bers of families coming together with other fami- typic assumptions about different cultural, racial, lies to learn and support one another. This form and ethnic groups. However, despite this actual- of therapy has been used to prevent risky behav- ity, exceptions and recognition of these idiosyn- ior in youth, strengthen families, and build com- crasies can be extremely important for individual munity cohesion [80, 112]. patient care. The CYP450 enzymes known for their metabolism of various drugs and toxic com- pounds are influenced by genetics and heritabil- Psychopharmacology ity as well as environment, which can also be shaped by ethnic influence. CYP2D6, the enzyme Pharmacotherapy, for certain illnesses, is a vital that metabolizes tricyclic antidepressants, selec- part of treatment, and unfortunately, African tive serotonin reuptake inhibitors (SSRIs), non- Americans utilize psychiatric medications at tricyclic antidepressants (mirtazapine lower rates than White individuals [113]. atomoxetine, venlafaxine), and antipsychotics Pharmacokinetics determines steady-state con- (clozapine, risperidone, haloperiodol, chlor- centrations of drugs and their metabolites. The promazine, perphenazine), is genetically highly 118 C. Bell and C. M. Crawford polymorphic. Due to this enzyme’s genetic vari- psychiatric conditions, considering the preva- ability, individuals can have different activity lev- lence of early childhood trauma in African els resulting in varying degrees of drug Americans [119]. metabolism classified as poor, intermediate, Lastly, studies have also demonstrated that extensive, or ultrarapid metabolizers [115, 116]. elderly African Americans may be more suscep- Additionally, CYP2D6 is responsible for the tible to tardive dyskinesia (TD), a severe condi- metabolism of multiple non-psychotropic medi- tion secondary to side effects related to cations including opiates, antiarrhythmics, beta- antipsychotics that can result in involuntary blockers, and antiemetics which can result in movements of the extremities and orofacial mus- unfavorable side effect profiles depending on the cles [120–122]. It is possible that variations in individual’s CYP2D6 activity level [116]. metabolism of antipsychotics contribute to this Research has demonstrated that the incident vulnerability of developing TD. of poor metabolizers is 1.9–7.3% in African In summary, evidence from differences in Americans compared to 3–10% in Whites. enzyme activity suggests African American However, researchers have identified a genetic patients should receive lower doses of many anti- variant in CYP2D6 found in 33% of African psychotic agents [123, 124]. However, African Americans which results in “intermediate metab- Americans routinely receive higher doses of anti- olizers” who typically do not experience drug psychotic agents, are more likely to receive depot toxicity at low doses, unlike poor metabolizers; injections, experience higher rates of involuntary however, they are more likely to experience med- psychiatric hospitalizations, and have signifi- ication side effects from lower doses [115]. The cantly higher rates of seclusion-restraints applied genes primarily responsible for lower CYP2D6 to them while in psychiatric hospitals [125–127]. activity levels resulting in poor and intermediate Further, African American adolescents with bipo- metabolizers is CYPD6∗17 and CYP2D6∗10. lar disorder were nearly twice as likely to receive The gene CYP2D6∗4 is found in Whites is antipsychotic agents (86% vs. 45%) than responsible for poor drug metabolizers [115]. European Americans [128]. Ethnic variation is a major confounding vari- Due to the increase in the antipsychotic medi- able in genetic studies and causes major difficul- cation side effects, extra pyramidal symptoms ties in understanding genetic coding systems that (EPS), and TD in African Americans, the newer interact with the environment and genes that atypical antipsychotic medications (i.e., risperi- determine the essential functioning of the brain. done, olanzapine, and quetiapine) may be of For example, there is a wide ethnic variation in a more value in treating these populations. repeat-length polymorphism within the promoter Unfortunately, atypical antipsychotic medica- region (5-HTTLPR) of the serotonin transporter tions impair glucose metabolism by causing insu- gene (SLC6A4) [117, 118]. African Americans lin resistance (unrelated to weight gain), cause are known to have lower frequencies of the allele significant weight gain, and are associated with responsible for shorter lengths of repeat hyperlipidemia [129]. Since many African sequences (S allele) compared to Whites. Given Americans have greater baseline risk for obesity, that serotonin transport in the brain has signifi- diabetes, and heart disease, this potential side cant clinical importance, this variant found in effect of atypical antipsychotics should be moni- African Americans could potentially play a role tored very closely in African Americans. In one in certain psychiatric conditions [117, 118]. longitudinal study in clozapine-treated patients, Caspi and his colleagues have shown that the S African American patients had dramatically ele- allele moderates the risk of depression primarily vated hazard ratio, compared to White patients, through an interaction with life stressors such as for both new-onset diabetes mellitus and death early childhood trauma [119]. These findings from myocardial infarction [129]. suggest that African Americans have unique Other biological concerns are the reality that genetic factors that could contribute to certain African Americans have a significantly lower 7 Psychiatry for People of African Descent in the USA 119 baseline white blood cell count than non-African African American women [132]. There is clearly American patients (“benign neutropenia”). This something around strengths to be discovered here may prevent trials or early discontinuation of clo- that can be applied to mental health treatment for zapine in this population, though the risk of PAD [133]. agranulocytosis appears to be the same as other Given that there is a lack of PAD in clinical populations [130]. trials, future research should also focus on their It is critically important for psychiatrists to inclusion [114]. The findings that arise from bet- establish firm rapport with African Americans ter representation can help the field understand before prescribing medications for them. It is treatment facets like dosing, efficacy, safety, and important because many African Americans have tolerability of psychotropic medications. New been inundated with antipsychiatry literature and drugs that are approved by the Food and Drug do not trust psychiatrists or the medication they Administration should be adequately studied in prescribe [131]. Understanding the patient’s/cli- PAD prior to being allowed on the market. ent’s beliefs about the causes of their problems Future research should also attend to the prev- and what they expect from treatment, neutraliz- alence and effects of fetal alcohol spectrum dis- ing their shame and fear of stigma, exploring order (FASD) in youth and adulthood. In Canada, their sources of strength and support, and ascer- FAS is quite prevalent in their juvenile justice taining their use of alternative medicine is critical system with a rate of 19:1 who have FAS [41]. to successful assessment and treatment. This research has not been conducted here in the Explaining potential side effects of medications USA. However, with the number of liquor estab- in an understandable manner (e.g., the short-term lishments in low-income Black communities and side effects of antipsychotic medication are shak- this noted idiom of distress, it is likely the USA ing, muscle cramps, and stiffness, and the long- would see a similar underlying picture [41]. First, term side effects are persisting abnormal the research should verify this probable reality, movements and weight gain) is more effective and then research and practice for African than a technical explanation that can be given Americans must move forward strongly in depending on the patient’s education. addressing and preventing this spectrum disorder. Prior to research on occurrence, we need a diagnostic tool that can be used in adolescence and Conclusion and Future Directions adulthood, for it is challenging to diagnose FASD without a baby picture or an honest answer from The field of mental health has significantly pro- a parent. Solving this issue may be potentially gressed since the days of enslavement as it relates transformative, as FASD may be a fundamental to treating PAD. However, there is still much to cause of disruptive behavior leading to (war- be learned and ways to grow. ranted) juvenile detention or special education (Note: we stress “warranted” to establish this as being different from and/or confounding the New Research Jim Crow phenomenon). The deficiency in choline that fetal alcohol exposure creates is hypo- More research is needed in understanding mental thetically responsible for the higher rates of health symptom manifestation for PAD. We need Alzheimer’s disease seen in African Americans. to develop valid and reliable tools for both Maternal choline supplementation has been pro- research and diagnosis—tools that use healthy posed as a prevention/treatment strategy for both PAD from different income brackets as the pri- Down’s syndrome and Alzheimer’s disease [134]. mary reference point to develop norms for This hypothesis is based on the finding that mice PAD. Additional research is also needed around (genetically altered mice to develop the neuro- the strengths and protective factors of PAD. For pathological changes in Down’s syndrome and instance, the rate of suicide is the lowest among Alzheimer’s disease within 6 months) have been 120 C. Bell and C. M. Crawford used to discover prevention/strategies for these given the mistrust and stigma persists [4]. In two disorders and research has demonstrated that addition, both non-White and White clinicians maternal choline supplements are a protective and researchers should be trained in cultural sen- factor against the degeneration of basal forebrain sitivity throughout medical training. Lu and cholinergic neurons seen in these two conditions. Primm [139] provide guidance in promoting cul- Thus, by increasing choline in prenatal vitamins, tural competence in medical school. Training in the scourge of fetal alcohol spectrum disorder cultural sensitivity and competence can be and Alzheimer’s disease in African Americans assessed using tools, such as the Association of may be abated [135]. American Medical Colleges’ Tool for Assessing Alzheimer’s disease is reported to be twice as Cultural Competency Training [140]. This tool high in African Americans compared to rates in includes items touching on history, knowledge, European Americans, and, while this may be skill, and attitudes in various facets of cultural related to the rates of fetal alcohol spectrum dis- competence including the impact of bias or ste- order in African Americans, something must be reotypes on decision-making. The Diagnostic done to treat the African Americans already and Statistical Manual, 5th Edition’s Cultural afflicted with Alzheimer’s disease [136]. Until Formulation [141], can also assist in manifesting the putative connection is made between fetal cultural competence in treatment of PAD [139]. alcohol spectrum disorder and Alzheimer’s disease is shored up by additional research, the problem of treating Alzheimer’s disease in Prevention African Americans needs to be explored. The first author’s clinical experience is that meman- Despite the efforts that have been made to tine and donepezil do not do a great deal to help increase access and improve healthcare quality patients with Alzheimer’s disease; however, esci- for people of color and low income, health dis- talopram does seem to decrease agitation such parities persist [6]. Prevention is one solution to patients, calms their anxiety, and brightens their this predicament. The near alleviation of polio affect [136]. Further, there is evidence that such through prevention is one exemplar of the power SSRI medications may significantly reduce amy- of prevention. We now know that prevention loid deposits in the brain and may be secondary saves millions of dollars, decreases violence, treatment strategy for patients with Alzheimer’s strengthens family, and saves lives [142]. disease [137]. However, while such clinical Fortunately, for mental health in particular, pre- research, also known as “bent nail” research vention is alive and well. However, there is still [138], may give important clues on how to significant work needed in this area. The infor- approach research on African Americans, there is mation provided in this chapter, regarding the still a great need to do formal academic research unique characteristics of African Americans, on these issues. various biopsychosocial factors, and implications of psychiatric treatment options, will hopefully encourage clinicians to integrate these principles Enhancing Cultural Sensitivity into practice, which could potentially mitigate psychiatric symptoms within this population. There are relatively few mental health professionals of African descent and definitely not enough to meet the mental health needs of References PAD. This simple ethnic matching could help to increase access to services, as Black mental 1. 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Joseph E. Trimble, Jeff King, Teresa D. LaFromboise, and Dolores Subia BigFoot

Selected Cultural Characteristics offered as to why the particular problem under and Perspectives on American investigation should persist within the individ- Indian and Alaska Native Mental ual or group. Yet the authors offer little in the Health Services and Treatment way of substantive and systematic recommenda- Approaches: An Overview tions or solutions for the diagnosed problems. with Reservations Moreover, they ignore the question of whether the problems are worthy of a solution from the In recent decades considerable research has perspective of the native people themselves. focused on the mental health, social pathology, State and federal governments, private founda- and psychopathology of American Indians and tions and organizations, and church-related Alaska Natives [1–5]. Most of the research institutions are aimed at resolving problems of offers interpretations as to the causes of a vari- Indian mental health, yet the problems still per- ety of emotional and behavioral disturbances. sist. A cursory examination of the social indica- Conjointly with theory, interpretations are tors indicative of mental health in any American Indian community would indeed support this contention. Authors Note: We wish to extend Dennis Norman, EdD, It is time for a reassessment of what has been Massachusetts General Hospital, Department of written, conceptualized, and put to use in treat- Psychiatry’s Center for Diversity and Harvard University’s ment and prevention. Mental health practitioners Native American Program our deepest gratitude and and scholars cannot continue to compile volumes appreciation for his kind and thoughtful assistance in contributing to the first edition of this chapter. of pragmatic, descriptive, and interpretative research without an ultimate objective. An objec- J. E. Trimble (*) · J. King tive of applied science is to offer practical solu- Department of Psychology, Western Washington tions to problems. However, a point has to be University, Bellingham, WA, USA reached where solutions must supplement under- e-mail: [email protected] standing. At present, it seems that research alone T. D. LaFromboise has been the outstanding feature of the focus on Graduate School of Education, Stanford University, American Indian and Alaska Native mental Stanford, CA, USA health. This calls for a revision in a basic concep- D. S. BigFoot tualization of the research model and the types of Department of Pediatrics, Center on Child Abuse and Neglect, University of Oklahoma Health Science data analysis that are or have been used, as well Center, Oklahoma City, OK, USA as their subsequent utilization.

© Springer Nature Switzerland AG 2019 127 R. Parekh, N.-H. T. Trinh (eds.), The Massachusetts General Hospital Textbook on Diversity and Cultural Sensitivity in Mental Health, Current Clinical Psychiatry, https://doi.org/10.1007/978-3-030-20174-6_8 128 J. E. Trimble et al.

Our purpose here is to reassess the current national and ethnic groups in European countries. knowledge available that describes the mental American Indians and Alaska Natives reside in health processes occurring among American 50 US states. An unknown number follow tradi- Indians and Alaska Natives. The inquiry will fur- tional lifestyles, and countless others embrace the ther clarify the structure and function of mental values and lifestyles of the common North health programs that have been established. American culture. The extraordinary variation in To present an overview of American Indians lifestyle orientations and physical appearance and Alaska Natives mental health issues, we have among American Indians and Alaska Natives purposefully avoided specific examples or presents a daunting challenge for anyone who generalizable guidelines that would mislead the tends to view American Indians and Alaska readers due to the extreme cultural and historical Natives as a homogeneous group [6]. differences that comprise the many American Indeed, the tendency of non-Natives to view Indians and Alaska Natives villages and nations. American Indians and Alaska Natives in a It is also important to note that in the context of collective manner has been a source of diversity, American Indian and Alaska Native considerable concern among scholars. It may identities are defined politically due to their well be the major reason so many non-Natives collective history of being citizens of sovereign experience difficulty in understanding the nations, not solely by racial, ethnic, or cultural complexity of the varied lifeways and terms. thoughtways of American Indians and Alaska The general terms, American Indian and Natives. Later, we present some definitions as Alaska Native, are used to describe the Indigenous well as information concerning demographic people of the continental United States; other patterns among American Indians and Alaska terms used in the literature include Indians, Natives to show how diverse the population is Treaty Indians, Tribal, Native Villages, Alaska and to demonstrate why it is impossible to create Native Villages, Native Corporations, Native a monocultural silhouette that portrays American, Native, First Americans, Tribal “Indianness” in a compendious manner. Mental Nations, First Nations, Indigenous Nations, health professionals must be aware of the American Indian tribes, Tribal people, Indian variations and distinctions if they want to work tribes, organized bands, Pueblos, Alaska Native effectively with American Indian and Alaska villages, tribal communities, Federally Native clients. recognized tribes, nonfederally recognized tribes, Historically, psychopathology, mental health, state recognized tribes, Rancherias, urban and personality among American Indians and Indians, reservation tribes, reservation Indians, or Alaska Natives (following a 1978 resolution by specific tribes. Many other tribally oriented the National Congress of American Indians, nonfederally recognized groups exist and may be people Indigenous to North America are referred seeking federal recognition of their status to as “American Indians” and “Alaska Natives,” including those tribes that are state recognized except when specific tribal designations are but not federally recognized. Federal recognized appropriate) held an enduring fascination as tribes designate a specific trust relationship with objects of study for social scientists. Native the federal government. scholars note the apparent unceasing stream of To effectively and competently provide men- biased research findings, case studies, and critical tal health services for American Indians and commentaries that flowed from researchers and Alaska Natives, one must understand the extraor- practitioners [7, 8]. dinarily diverse demographic and individual Moreover, a majority of programmatic efforts identity characteristics of the groups that make to provide services in American Indian and up North America’s Indigenous populations. Alaska Native mental health were guided by These populations are no doubt more diverse Euro-American psychiatric and professional tra- than those that make up the rich tapestry of ditions (see [9, 10]). It has been demonstrated 8 American Indian and Alaska Native Mental Health 129 that the Euro-American practices conflict with several critical components, such as care, the basic worldview of many American Indian specifically, the delivery structure itself, treatment and Alaska Native communities [11]. processes, program evaluation, epidemiological Continuation of these practices will in all data, and preventive strategies. However, as a likelihood create more problems than are solved. more informed perspective toward American Miranda et al. [12] reported that American Indian Indian and Alaska Native mental health is and Alaska Native populations are largely emerging, federal and state agencies are now missing from the literature on the effectiveness of initiating and implementing new and more mental health care and that the limited literature culturally sensitive mental health programs. focuses on prevention strategies with American Simultaneously, more accurate research and Indian and Alaska Native youth. Bernal and reporting are emerging. For example, recently Scharron-Del-Rio [13] suggest that, “it is essen- many federal agencies have developed initiatives tial that researchers construct theories of psycho- under the directive of health disparities research therapy and evaluate treatments grounded in the to promote preventive intervention efforts in realities and experiences of ethnic minority pop- American Indian and Alaska Native communities ulations” (p. 337). In addition, Bernal and Saez- [10, 15, 16]. These interests and the initiatives are Santiago [14] reported that too few studies have positive steps and have potential for improvement (a) incorporated culture and ethnicity as part of of mental health conditions. the intervention, (b) tested the effectiveness of While improvements have been made, a recent such interventions, (c) articulated and report by the Department of Health and Human documented how ethnicity and culture play a role Services Office of Inspector General [17] found in the treatment process, and (d) described how that: interventions may need to be adapted or tailored to meet the needs of diverse families. • Eighty-two percent of Indian Health Service There have not been many studies about (IHS) and tribal facilities reported that they American Indian and Alaska Native attitudes provide some type of mental health service; regarding mental health and mental illness. There however, the range of available services is is a general American Indian and Native Alaska limited at some facilities. worldview that encompasses the notions of • Staffing issues and shortages of highly skilled connectedness, reciprocity, balance, and providers limit American Indian and Alaska completeness that frames their views of health Native access to mental health services at IHS and well-being. Studying this experience may and tribal facilities. help lead to the rediscovery of the fundamental • Physical, personal/social, and economic chal- aspects of psychological and social well-being lenges may affect access to mental health ser- and the mechanisms for their maintenance. vices at IHS and tribal facilities. In the last three decades, mental health services delivered to American Indians and Alaska The report concluded that the high rates of Natives have grown dramatically in terms of gen- suicide, substance abuse, depression, eral availability as well as in the range of care unemployment, and poverty in American Indian offered. This growth can be attributed to a num- and Alaska Native communities demonstrate the ber of factors, notably changes in federal public need for access to mental health services. health policies, increasing tribal resources and Although over 80% of IHS and tribal facilities expertise, and community demands for more reported that they provide mental health services, comprehensive and “culturally relevant care.” these services are limited by shortages of highly The rapid expansion of mental health services to skilled providers and specialty areas and by other American Indians and Alaska Natives has, staffing issues. Furthermore, the majority of however, frequently preceded careful American Indians and Alaska Natives seeking consideration of a variety of questions about these services live in rural areas and face physical, 130 J. E. Trimble et al. personal/social, and economic barriers that limit highest rate of suicide was with Native females access. The report recommended that IHS: aged 15–19; suicide was the sixth leading cause of death for American Indians and Alaska Natives • Provide guidance and technical assistance to males of all ages. Suicide ranked first in leading help tribes explore potential partnerships with cause of death for females aged 10–19 and second non-Indian and Native providers of community leading cause of death for Native males aged mental and behavioral health services. 10–34. They also reported that in this same • Continue to expand its telemedicine capabili- period, American Indian and Alaska Native males ties and provide guidance and technical assis- in the 15–19 age range had the highest suicide tance to tribal health-care providers to expand rate compared to same-age males of all other and implement telemedicine. ethnic groups. • Develop a plan to create a single database of A recent report by scholars of American Indian all IHS and tribal health-care facilities. Alaska Native suicide linked suicide to behavioral health problems, such as anxiety, substance abuse, Mental health disorders are a known risk fac- and depression and also called attention to victim- tor for suicide in the general population and ization, discrimination, and acculturation stress ranked second of the ten leading causes for [18]. They also reported that in this same period, hospitalizations among American Indians and American Indian and Alaska Native males in the Native Alaskans aged 5–14 and 15–24 in 2016 15–24 age range had the highest suicide rate com- [8]. Recent data on the prevalence of specific pared to same-age males of all other ethnic mental disorders among this population are groups. They linked suicides to distrust of formal limited, but evidence suggests they are at services, underutilization of services, lack of increased risk for a range of mental disorders due resources to ensure safety (e.g., absence of law to historic trauma and low utilization rates for enforcement on rural reservations, rural allot- mental health services [9, 10]. ments, and Alaska Native villages), ongoing mar- American Indians and Alaska Natives experi- ginalization, poverty, underemployment, lack of ence serious psychological distress, 1.5 times basic services, and collective disempowerment more than the general population [8]. American [18]. Finally, other reports note the major disrup- Indians and Alaska Natives experience PTSD tive impact of forced assimilation across genera- more than twice as often as the general populations on tribal unity, family strength, and typical tion [8]. Although overall suicide rates are simi- coping strategies [19]. lar to those of whites, there are significant Some key protective factors against suicide differences among certain age groups. Suicide is attempts among Native youth include [20] dis- the second leading cause of death among 10–34- cussion of problems with family or friends, con- year olds American Indian and Alaska Natives, nectedness to family and community, and whereas the suicide rate among Native people building motional health. But there are major that are more than 75 years old is only one-third barriers to accessing mental health that include of the general population [8]. Also American economic barriers (cost, lack of insurance), lack Indians and Alaska Natives use and abuse alcohol of awareness about mental health and available and other drugs at younger ages, and at higher services, stigma associated with mental illness, rates, than all other ethnic groups which is a lack of culturally sensitive mental health services, factor in suicide attempts and completions with mistrust of health-care providers, limited mental this population. health services, and lack of appropriate The Center for Disease Control and Prevention, intervention strategies (including integration of for example, reports more specifically that from mental health and primary health-care services). 2003 to 2014, the suicide rate for American Given the long history of limitations and mea- Indians and Alaska Natives has been increasing ger and misguided attempts at delivering formal and was higher than the overall US rate; the services, it is not surprising that the recognition 8 American Indian and Alaska Native Mental Health 131 of the stark and immediate needs in these com- sufficient “degree of Indian blood” to qualify munities due to explosive growth outstripped the them for specific tribal enrollment but may still knowledge for designing and implementing be eligible for IHS or Bureau of Indian Affair appropriate programs. The time has come to take services due to their combined “degree of Indian stock of the current situation. blood.” Tribal nations have unique governments, To this end, we selectively review the litera- histories, traditions, communities, languages, ture relevant to many of the areas listed above. A and behavioral health challenges [21]. Compared series of questions are posed as points of to the total US population, more than twice as departure for future inquiry, the answers to which many American Indians and Alaska Natives live will, in our opinion, form the basis for significant in poverty. In 2013, American Indians and Alaska advances in the delivery of mental health services Natives men and women were nearly twice as to American Indian and Alaska Native people. likely as whites to be unemployed [23]. Before turning to a discussion of specific aspects American Indian and Alaska Native commu- of the delivery of mental health services to this nities are culturally heterogeneous, having been special population, some mention of the broader classified into distinct regions in terms of differ- context is in order, particularly for readers who ences in language, social organization, religious may be unfamiliar with these communities. practice, and ecological relationships. Of the over 300 major American Indian and Alaska Natives languages that existed immediately prior to Demographic Patterns European contact, approximately 150 are still spoken, excluding hundreds of dialectal varia- As of 2012, an estimated 5.2 million people were tions. To put this into perspective there are about classified as American Indian and Alaska Native 500 distinct languages spoken among the alone or American Indian and Alaska Native in Indigenous peoples of the vast Amazon basin in combination with one or more other races which South America. is about 2% of the total US population. Twenty- Within the framework of American Indians two percent of American Indians and Alaska and Alaska Natives populations, the barriers to Natives live on reservations or other trust lands. mental health treatment are formidable and Many of these lands are remote and cover vast include quality of care (e.g., fragmented service geographic areas that may have limited access to system, limited funding, unavailable services, behavioral health services. Between 60% and and racism) coupled with the desire for self- 70% of American Indians and Alaska Natives live reliance, privacy issues, communication/trust, in urban areas—the lowest metropolitan percent- and fear of mental health treatment [24]. There age of any racial group. 1.5 million (30%) of are vast differences in what exist from having no American Indian and Alaska Natives are under trained service providers within a 200-mile range the age of 18. The 2010 Census revealed that 78% to the recent establishment of an Indigenous of American Indians and Alaska Natives live out- private practice behavioral health clinic on a side of tribal statistical areas ([21, 22], retrieved reservation. September 7, 2018 from: https://minorityhealth. Overall, American Indians and Alaska Natives hhs.gov/omh/browse.aspx?lvl=3&lvlid=62). are less likely to have access to mental health ser- Currently, there are 573 federally recognized vice than the general population, receive poorer American Indian and Alaska Native tribes, and quality care, and are underrepresented mental more than 100 state recognized tribes. There are health research [25]. In 2010, Senator Byron also tribes that are not state or federally Dorgan, then Chairman of the Senate Committee recognized. To add to this complexity, some on Indian Affairs, released a report citing problems American Indians and Alaska Natives people are in some IHS facilities related to credentialing and members of a tribe, whereas others who are also licensing of providers, accountability of controlled American Indian are not. They may not have substances, and management of funds. These 132 J. E. Trimble et al. problems were similar to those previously identi- support programs, tribal health departments, and fied by the Office of Inspector General (OIG) and detention facilities and jails [30]. The nature and the US Government Accountability Office (GAO). extent of services delivered vary with each Prior to that, in 1999, and again in 2004, the US agency or community organization, as does our Commission on Civil Rights found significant knowledge concerning their respective client health disparities for AI/ANs as a result of struc- populations, problems treated, and outcomes. tural and financial barriers, many of which were similar to problems identified almost a century ago [26]. The barriers to treatment include a frag- State and Local Services mented service system, limited funding, unavailable services, and racism coupled “with distrust Very little information exists on client profiles and and fear of mental health treatment.” diagnostic distribution for American Indians and The service provision for all American Indians Alaska Native seeking services from private agen- and Alaska Natives is problematic as there are a cies. Given the availability of services provided limited number of professionals trained to work by other institutions, it is likely that relatively few with American Indians and Alaska Natives. The individuals seek private care. Numerous American need for appropriate and accessible mental health Indians and Alaska Natives from both urban areas services in Indian Country is enormous [27]. and reservations are served by county and state Mental health services to American Indians and mental health facilities. However, the diverse Alaska Natives are delivered by a diverse array of points of entry into this system—such as state providers, many acting through federal agencies, hospitals, day treatment centers, the Social some through locally controlled organizations, Security Administration, CETA, Department of and others as part of private as well as state- Justice, hospital emergency rooms, and voca- managed systems. Eligibility criteria are even tional, rehabilitation sectors—yield a confusing more confusing and vary with the provider agency and often unmanageable set of service use data. question. Indeed, this confusion prompted a study American Indians and Alaska Natives appear to sponsored by the US Department of Education, use mental health services far less frequently than Office of Indian Education [28], to determine their need for services would suggest [31]. The workable definitions of “Indian.” Despite the American Indian Service Utilization and “definition” of Indian study, bureaucratic ambigu- Psychiatric Epidemiology Risk and Protective ity remains, employing tribally defined member- Factors Project reported that between 21% and ship criteria which differ across regions, blood 24% (depending upon the tribe) of an American quantum (frequently one-fourth, genealogically Indian sample were diagnosed with any alcohol, derived), personal identification/community con- drug, and mental disorder compared to 22% sensus, and various permutations thereof [29]. It reported by non-American Indians in the National is within this setting, then, that the following Comorbidity Study [32]. Reasons for low inci- issues and concerns arise. dence of seeking mental health services included use of primary care for mental health rather than specialized care, most likely due to stigma associ- Delivery of Services ated with emotional or mental health treatment, privacy issues associated with confidentiality Mental health services to American Indians and (e.g., having to receive care at facilities where Alaska Natives are provided through private friends and relative work), and negative social agencies and practitioners, county and state support or criticism for seeking help from people agencies, community mental health centers, the in their social network. Furthermore, clients with Bureau of Indian Affairs, Bureau of Indian anxiety disorders who had concerns interacting Education, the Indian Health Service, Veteran with others were also reluctant to seek mental Administration, urban Indian health and family health services [33]. 8 American Indian and Alaska Native Mental Health 133

Bureau of Indian Affairs The Indian Health Service

The Bureau of Indian Affairs (BIA) serves tribal The Indian Health Service (IHS) annually pro- governments in the administration of employ- vides inpatient and outpatient care to more than ment and job training assistance, law enforce- two million American Indians and Alaska ment and justice, agricultural and economic Natives, through direct or contract services in 12 development, tribal governance, and natural regional areas each harboring approximately 772 resources management programs to enhance the facilities of hospitals, clinics, and satellite centers quality of life in federally recognized tribal [17]. A relatively new but growing component communities located in 34 states. Historically, administers social service and mental health the BIA’s responsibilities included providing programs. Because of varying and limited health-care services to American Indians and resources, service provision can range from Alaska Natives. However, in 1955 the responsi- exemplary to extremely lacking. Many facilities bility was legislatively transferred as the Indian are not able to provide mental health services due Health Service to the US Public Health Service to staff shortages of psychiatrists and other within the Department of Health, Education and licensed providers [17, 34]. Welfare, now known as the US Department of Health and Human Services (DHHS). The BIA is also responsible for the administration and Urban Indian Health-Care Programs management of 55 million surface acres and 57 million acres of subsurface mineral estates held Beginning in the early 1970s, American Indian in trust by the United States for American and Alaska Native communities started to assume Indian, Indian tribes, and Alaska Natives. The direct control of the management and provision of Bureau of Indian Education (BIE) is a branch of health services to their members. At present there the BIA and provides education services to are approximately 40 urban American Indian and approximately 42,000 American Indian and Alaska Native health programs. These pro- Alaska Native students. This responsibility is grams—authorized under Public Law 93–437, the met through tribal and state contracts, federal Indian Health Care Improvement Act, and imple- boarding schools, and educational and voca- mented on a contractual basis with the Indian tional guidance programs. This branch of BIA Health Service—have only recently expanded to encompasses child welfare, including care, include mental health care and then on a limited supervision, and other services for delinquent, basis. Urban Indians are much more likely to seek dependent, or neglected children, and family health care from urban Indian health organiza- services involving counselor interventions tions (UIHOs) than from non-Indian clinics [35]. related to family breakdown and emotional However, these Indian-operated clinics must instability [34]. Mental health professionals and struggle to obtain and maintain their funding, paraprofessionals are employed in both resources, and infrastructure needed to serve this branches. However, their diagnostic observa- growing population. The vast majority of tions are seldom a matter of formal record; at American Indians and Alaska Natives living in best they are expected to refer clients to mental cities are ineligible for or unable to utilize health health-care providers, such as the Indian Health services offered through the Indian Health Service Service or the tribal-based behavioral health or tribes (i.e., because of access to a facility or services. Typically, there is little or no postrefer- tribal enrollment difficulties), so the UIHOs are a ral monitoring. One primary concern of many key lifeline for this group. The Indian Health BIE boarding schools is the placement of youth Service contracts with private Indian-controlled directly from residential care without formal nonprofit corporations to run UIHOs. Today, there follow-up or referral into BIE schools [34]. are 34 UIHOs. In fiscal year 2015, Congress spent 134 J. E. Trimble et al.

$41 million on the program, or about 0.01% of Health Service. Less than half of these programs IHS’s $6 billion annual budget. The 34 organiza- have a formal mental health component due to tions served roughly 100,000 Indian people in similar reasons mentioned with urban and federal 2005. services: lack of adequate funding, lack of quali- However, there is no formal public health sur- fied providers, isolated location, stigma, and lack veillance system for urban Indians. Federal, state, of priority by tribal government. and local public health institutions might collect such data, but they are rarely disaggregated or separately analyzed [36]. Many standard federal Service Delivery Considerations health surveys cannot report accurately on urban Indians, in part because they lack adequate racial The American Indian and Alaska Native service designations. In one effort to address some of delivery system is a complicated mixture of these gaps, the Urban Indian Health Institute was multiple service entities guided and impacted by created as a division of the Seattle Indian Health jurisdictional overlays that create significant Board in order to unify data from the UIHOs, problems in the delivery of trauma services. identify urban American Indian and Alaska According to Manson [27], the system of ser- Native health needs, and to clarify health dispari- vices for treating mental health problems in ties [37]. The majority of current urban American “Indian Country” is a complex and inconsistent Indian and Alaska Native health data available is set of tribal, federal, state, local, and community- the work of the Urban Indian Health Institute. based services. The agencies directly responsible A summary of urban mental health problem are Indian Health Service, Bureau of Indian areas in 2007 indicates that (1) American Indian Affairs, and the Department of Veterans Affairs; and Alaska Native children, adults, and families other programs providing services are the have significant and multiple mental health needs, Department of Justice Office for Victims of and (2) these needs lie especially in the areas of Crime, the Office of Juvenile Justice and chemical dependency, vocational/employment/ Delinquency, and Office of Tribal Affairs and financial, family, learning, emotional and inter- tribal health programs; urban Indian health pro- personal, and cultural difficulties. Among the grams; state and local service agencies; schools total population, the most frequent problem areas including profit, nonprofit, and/or religious; and were: chemical dependency, family strife, learn- traditional healing resources. Manson’s 2001 ing disability or difficulty, physical complaints, report on “Mental Health Care for American and employment. While these issues present Indians and Alaska Natives” states that while the themselves at these facilities, this pattern is need for mental health care is significant, the ser- thought to be representative of just a fraction of vices are lacking, and access can be difficult and the broader American Indian and Alaska Native costly [39]. The report lists problems in service community [38]. utilization patterns that include American Indian and Alaska Native children as being more likely to (1) receive treatment through the juvenile Tribal-Based Health-Care Programs justice system and inpatient facilities than non- Indian children, (2) encounter a system A similar set of circumstances characterizes tribal understaffed by specialized children’s mental health programs. Reservation communities are health professionals, and (3) encounter systems empowered to assume either partial or total with a consistent lack of attention to established responsibility for the delivery of a wide range of standards of care for the population. The services, including mental health care, as part of proliferation of services within the delivery Public Law 93–638, the Indian Self-Determination structure outlined above raises a large number of Act. To date, 115 different tribal programs have critical questions, the answers to which can guide been established under contract to the Indian future growth and create greater efficacy in care: 8 American Indian and Alaska Native Mental Health 135

Is there a relationship between the form of rituals, and ceremonies that help connect the delivery structure and the degree of service physical world with the spiritual world to bring utilization (frequency of return—as well as initial about wellness, balance, and harmony. The contact)? What are the channels by which spiritual dimension is interwoven and intertwined information about service availability is with the physical, mental, emotional, and rela- communicated to and among American Indians tional well-being dimensions [40]. Johnson and and Alaska Natives? What service programs have Cameron in their [41] review of mental health successfully engendered participation in planning services with American Indians note the frequent and operation? How have they accomplished use of traditional healing on a regular basis by this? Does participation relate to differential both urban and reservation dwelling members of program effectiveness? How so? What impact this population. King [35] found that more than will federal policy changes in service delivery half of urban American Indians and Alaska control and eligibility requirements have on Natives had wanted traditional healing in the past delivery structure and subsequent organizational year. Robert Bergman writes about medicine men development? To what extent can service that were able to provide types of healing that duplication be avoided? How can service delivery Western medicine could not provide, including be restructured to render existing health resources the healing of schizophrenia [42]. He mentions more cost-effective? What is the rate of referral one case in particular: compliance by American Indian and Alaska ... a woman who had been hospitalized several Native clients? To what extent is it affected by times as a schizophrenic. A social worker and I set different eligibility requirements across services? out to track her down to see how she was. We How can one increase such compliance? found her father first. He agreed to take us to see her but said that maybe we wouldn’t be interested anymore because now she was perfectly well. We said that if she was perfectly well, we were even Native Traditional Healers more interested in seeing her. She was at home and Collaboration taking care of several very active, healthy-looking children and weaving a rug at the same time. After a visit of several hours, we agreed that she was Though this chapter focuses on the formal mental indeed well again. (p. 8) health delivery structures, one should be aware of the important and extensive role that traditional We would do well to collectively and more healers play in the mental health care among seriously consider what traditional healers are American Indians and Alaska Natives. The able to offer the field of mental health as well as function of Native traditional healers and their develop integrated, holistic services. relationship to Western health-care professionals is an essential but not a necessarily utilized collaboration. It is our opinion that any effort to Treatment Approaches plan and deliver mental health services to Native communities must take the potential impact upon Counseling and psychotherapy outcome traditional healing practices into account. Central research has emphasized the importance of cli- to wellness and healing is the American Indian ent or patient variables, expectation, and degree and Alaska Native belief held by many traditional of disturbance, therapist characteristics, and people that all things in life have a spiritual related factors and considerations. The develop- nature. It is important to have this understanding. ment of a facilitative relationship or working Spirituality as part of the healing process alliance is also of considerable importance. This continues to play an important role in the interpersonal climate is thought to result from individual and collective well-being of American the ability of the therapist to understand the cli- Indians and Alaska Natives; helpers and healers ent and to communicate this understanding ade- have been taught words, prayers, practices, quately [43]. 136 J. E. Trimble et al.

Therapy in cross-cultural settings, which char- change in ways that are congruent with the ther- acterizes the vast majority of American Indian apist’s goals and value system [46]. Although and Alaska Native mental health experiences, has they may be motivated to seek treatment, they its most serious problems in those very areas of probably do not share as many valued directions interaction that have been demonstrated to affect of change as participants from the therapist’s psychotherapy outcome. Cross-cultural therapy cultural background and training. Trimble [47] implies a situation in which the participants are makes exactly this point, citing major differ- most likely to evidence discrepancies in their ences between White and Lakota [48], Pueblo shared assumptions, experiences, beliefs, values, [11, 49], Hopi [49], and Arapaho [50] cultural expectations, and goals. Several recent literature values. Moreover, American Indian and Alaska reviews indicate that in the absence of this open- Native clients may hold quite different beliefs ness, this situation, at its extreme, establishes about the etiology of their problems and the conditions that are clearly unfavorable for suc- manner in which change can be accomplished cessful therapy, whereas effective cross-cultural [51–54]. therapy allows for the safe and open exploration of these discrepancies. This view is supported by the subjective reports of many clinicians involved Characteristics of Service Providers in cross-cultural psychotherapy, as well as the limited cross-cultural research conducted in this Certain therapist characteristics, qualities, and domain [43, 44]. activities have been identified as contributing to positive and negative outcomes in psychotherapy in general. In fact, many clinicians believe these Complexities in Counseling qualities to be the most important determinants and Psychotherapy of patient improvement. Therapist variables such as warmth, honesty, self-disclosure, empathic Given a history of hegemony and cultural annihi- communication, specific personality lation, how might an American Indian and Alaska characteristics, and personal adjustment are Native client experience therapy? Among the among those that have received the greatest most notable difficulties is the client’s inaccurate attention in empirical studies. This research was or inappropriate perception of the therapist’s role initially summarized by Strupp [55], among oth- and client responsibilities. Thus, there is often a ers, and has been updated on several occasions discrepancy between what the client expects and [42, 56]. The evidence indicates that the quality what the therapist interprets as the most benefi- of the relationship correlates with positive cial role. This same theme has been emphasized outcomes. [45, 46] in discussions of the difficulties often Cross-cultural research suggests that many of inherent in attempts by non-Natives to work with the same therapist characteristics are also related American Indian and Alaska Native clients. They to positive outcome between participants from suggest that, in general, traditional therapeutic different cultures. Perceived expertness, positive forms of social or interactional control and influ- regard and empathy, comfort, and previous cross- ence are viewed by American Indians and Alaska cultural experience have been shown to be related Natives as out of the realm of proper behavior of to different culture client improvement [57–60]. action and that American Indian and Alaska Considerably more work needs to be done in this Native clients frequently react with disquiet, fear, regard, especially with respect to the manner in or bewilderment. Clear differences exist and do which such variables are defined and affect subsequent outcomes. operationalized. Little or no data are available on In addition to the expectations for role per- the therapist variables most closely linked to formance, the clients of cross-cultural therapy positive outcomes in psychotherapy among do not always find themselves motivated to American Indian and Alaska Native clients. 8 American Indian and Alaska Native Mental Health 137

Speculation and anecdotal impressions abound response (in the form of modification or redirec- yet remain to be evaluated systematically. tion) rarely follows. This seems to be true of the delivery of mental health services in general as well as in the American Indian and Alaska Native Treatment-Related Considerations case [64]. However, for many of these communities, culturally specific, community-driven inter- To this end, the following questions must be ventions often lack systematic research and examined within American Indian and Alaska evaluation to support their effectiveness. Native communities: (1) What treatment Utilizing science to assist with evaluation is modalities (Indigenous and nontraditional) are problematic because scientific methodologies available for various forms of psychopathology? are developed from a worldview that differs sig- (2) What expectancy variables define the nificantly from Indigenous communities. Thus, therapeutic relationships? (e.g., cultural it is quite difficult for tribes to bridge scientific awareness of the therapist, consideration of measurement with Indigenous knowledge (e.g., cultural aspects in treatment) From the American what constitutes success, how do local commu- Indian and Alaska Native patient’s viewpoint? nities evaluate effectiveness, etc.) [62]. From the therapist’s viewpoint? (3) What process variables occur between therapists and American Indian and Alaska Native patients? (4) How does Utilization of Services one appropriately measure outcome? (5) What constitutes effective treatment? (6) To what With one major exception, which is discussed at extent and under what conditions are treatment the end of this section, the evaluation of services modalities differentially effective? (7) Under delivered to American Indians and Alaska Natives what conditions and for what reasons are has taken the form of studies of reasons for practices and techniques of traditional healers underutilization, or, more specifically, barriers to appropriate? The importance of these questions service. Murdock and Schwartz [65] surveyed cannot be understated. Many Indian and Native 160 elderly Lakota residents of a South Dakota communities are now focusing on approaches reservation and found the overall awareness of that include decolonization and recovery of available services to be remarkably low. More traditional knowledge as central to their health than 40% of the respondents were unaware of 15 and mental health. They seek ways to demonstrate of the 21 service agencies on the reservation. that their culture-based or culture-assisted inter- Awareness of service availability closely ventions and approaches have accomplished their paralleled previous differences in perceived need intended purpose [61–63]. by household type. Elderly persons living alone were less aware of medical, home maintenance, and personal maintenance services than their Program Evaluation counterparts residing as couples or with children. Moreover, the former were more aware of social Program evaluation proceeds at a different level and mental health services, for which they of analysis than does the measurement of treat- expressed considerable need, but that were sorely ment outcomes. It examines specified organiza- lacking. King [35] found that approximately half tional and service delivery goals in the context of of an urban Indian sample were not aware of and community needs and the subsequent impact of did not know how to access basic health services. an intervention scheme. Planners and adminis- Additionally, beliefs about the effectiveness of trators of American Indian and Alaska Native mental health-care staff can affect use patterns. programs advocate evaluation of this nature, but Reporting on their work among the Navajo, seldom practice it. In those few instances in Schoenfeld et al. [66] indicate that patient refer- which such efforts are carried out, program rals are directly related to the attitudes that pro- 138 J. E. Trimble et al. gram staff holds toward the provider agencies. there is much to address before services are For example, few, if any, clients were referred to adequate, effective, congruent traditionally, and the BIA program since attitudes toward its staff utilized by Indian and Native people in need. were largely negative. Furthermore, whereas the mental health personnel were viewed positively, a great deal of mistrust existed between them and Evaluation-Related Considerations other agencies, hampering effective coordination of the delivery of services in this community. The limited focus of past evaluation efforts sug- Similar results were reported by Saylors and gests that we must begin to ask a series of broader, Daliparthy [67]. more comprehensive questions: (1) What ser- Urban American Indian and Alaska Native vices currently maintain an active program evalu- leaders and community members share a mutual ation component? What is this component’s concern for mental health conditions and avail- function? How are data collected and used to ability of services [68, 69]. According to Clark inform development? How can culturally adapted [70], urban American Indians believe that their evidence-based treatments respectfully be evalu- mental health needs are not being met adequately ated with American Indians and Alaska Natives? and that the federal government shares in the (2) What evaluation models are available in gen- responsibility for providing care. Furthermore, eral, especially those culturally appropriate for available services are viewed with suspicion and use in certain American Indian and Alaska Native hence are underutilized, a recurrent finding areas? Are there program examples? (3) Are cer- among American Indian and Alaska Native popu- tain types of evaluation more appropriate for one lations and other ethnic minority populations delivery structure than for another? (4) What are [71]. Nonurban and off-reservation American the major barriers to program evaluation? How Indian and Alaska Natives apparently experience can these be overcome? (5) How does one mean- problems similar to those of their urban counter- ingfully apply evaluation data to program devel- parts. Many off-reservation American Indians opment? (6) What efforts are being made to and Alaska Natives and those who have been evaluate the effectiveness of traditional healers in “disenrolled” have ambiguous status; state and providing services or the effectiveness of collab- federal governments typically consider them to orative efforts between professionals and heal- be outside the realm of their responsibility. ers? (7) What are the competencies required for Nonetheless, their need for services is as great as delivering effective mental health services in those of American Indians and Alaska Natives American Indian and Alaska Native areas? Must from other settings perhaps greater, considering all programs fit the cultural needs of communi- the few services available to them. ties? Or must the orientation of the clientele be A recent study among American Indians from adjusted to accommodate the limitations of the several Plains tribes found that those who had programs? To what extent are these issues being more positive attitudes toward mental health researched and assessed? services were female and those who had greater Indigenous mental leaders in policy, practice, social support. Those who had negative attitudes and research from Canada, United States, were tribal members who were more traditional Australia, Samoa, and New Zealand met in 2009 in their beliefs; those who were older and those and under the leadership of Sir Mason Durie, who had higher chronic medical conditions. Māori professor, founded the Wharerātā Group. There was a caveat among older adults where This group supports Indigenous leaders working with good health insurance tended to have more in mental health and addictions and collaborates positive views [72]. While there are glimmers of to integrate best practices for Indigenous people. acceptance and positive attitudes toward mental In the initial meeting, the participants quickly health services, these appear to be limited and found shared concerns of higher rates of mental 8 American Indian and Alaska Native Mental Health 139 illness and inconsistent culturally competent Epidemiology services from mainstream health systems. They issued the Wharerātā Declaration [73]. Epidemiological data are requisite to the cost- The Wharerātā Declaration provided five prin- effective deployment of mental health resources ciples foundational to Indigenous health and and are especially important when said resources mental health: are limited, as is the present case. Several studies report diagnostic distributions and prevalence 1. Indigeneity, which means the protection and rates and explore the relationship between maintenance of cultural knowledge, also psychiatric morbidity and contemporary social known as Indigenous intelligence. pressures [74]. Though open to various method- 2. Best or Wise Practice, which means that in ological criticisms, these kinds of data provide a mental health, Indigenous intelligence is the broader and more divergent picture of the nature starting point and mainstream knowledge is and pattern of disorder in American Indian and added as appropriate. Alaska Native communities than those that derive 3. Best or Wise Evidence, which means that from service utilization studies, by far the more evaluation is based on the origin of the common approach to estimating such trends [64, intervention; that is, if an intervention is 75]. cultural, then the evaluation methodology must be based on cultural knowledge. 4. Indigenous Leadership, which means that Epidemiological Considerations although change is needed at a systems level, it must be based on Indigenous intelligence; Future epidemiological work among American this means that the Indigenous mental health Indian and Alaska Native communities must leader must be: address the following questions: (1) To what –– Informed in both cultural and mainstream extent are current diagnostic tools valid and knowledge and able to switch between the reliable indicators of psychopathology as two “languages” to strengthen communica- perceived and experienced by American Indians tion skills and Alaska Natives? (2) What is the relationship –– Credible with our home community/net- between “treated” prevalence and incidence rates work as well as with mainstream peers (derived from service records) and patterns of –– Strategic in thought and leadership to build disorder as manifested in the community at large? alliances and partnerships (3) Are the data that serve as the basis for –– Connected to protect and strengthen net- “treated” prevalence and incidence rates collected works across sectors including mainstream in a reliable, systematic fashion? (4) Can these mental health, Indigenous mental health, data be organized, collated, and reported in a political, and funders regular, relatively current, and accessible form? –– Self-sustainable as we work to maintain (5) Can a mechanism be developed to translate our own work-life balance and to build such data into meaningful recommendations for future leaders to take over for us the development of mental health services to 5. Indigenous Leadership Influence—use of our American Indians and Alaska Natives? positive influence through our networks, with our peers, based on our credibility, is a strategic approach to changing systems to bet- Collecting and Measuring Mental ter serve Indigenous clients [73]. Health Data

In response to the first question, recent studies indicate the methodological and conceptual 140 J. E. Trimble et al. shortcomings of several diagnostic instruments and the Bureau of Indian Affairs. Some attention when administered to members of American needs to be given to how the kinds of data Indian and Alaska Native populations. Regardless described above can be introduced into such a of the scale of interest, the scores of nonpsychotic network to ensure appropriate consideration in depressed American Indian and Alaska Native the design and modification of mental health patients can be indistinguishable from the scores services, both those currently delivered and those of schizophrenic American Indian and Alaska planned. Successful efforts in this regard will Native patients [44]. On the basis of these find- probably prove to have had multiple points of ings, researchers conclude that the similarity of contact with unequivocal relevance and strong subgroup profiles demonstrates significant cul- community support [39, 78]. tural influence on the response patterns, rendering the MMPI useless among American Indians and Alaska Natives [60, 76, 77]. Clearly, answers Prevention to questions about reliability and validity of diagnostic tools among American Indian and Alaska Prevention approaches, especially those that Native communities await careful studies such as involve mental health promotion and these. enhancement, have long held the interest of tribal There is little or no indication in the literature planners and service providers, the Indian Health as to the relationship between “treated” Service, local as well as national advisory boards, prevalence and incidence rates and patterns of and American Indian and Alaska Native people. disorder at the community level in the American This interest stems from a community-derived Indian and Alaska Native population. No service sense of self and of others that lends itself to the utilization records were available for comparison public health model that underpins the Western among the communities in which epidemiological health-care system introduced into Indian coun- studies have been conducted previously. try through past treaty arrangements [79]. The Indian Health Service collects mental Moreover, Indigenous approaches to health and health data systematically across its 12 service welfare at the levels of the individual and of the unit areas. A computerized patient care tribe provide fertile ground for the growth of such information system has been implemented in concepts. Traditional healers, their patients, some of the service areas and, depending upon significant others, social context, and common availability of funds, will be put into effect ethos are intimately linked in an attempt to realize service-wide in the near future. The protocols for many of the same goals as those expressed in the collecting data of this nature have not been National Institutes of Health (NIH) prevention examined in terms of inter-rater reliability, which policy, specifically family cohesion and positive is further complicated by the disparate educational family relationships; positive well-being, a basic backgrounds and varied training of service belief in one’s self-worth and relative value to the providers. Until common valid diagnostic world, however personally defined; respect for procedures are adopted and the reliability of the others; interpersonal and social skills necessary collection of patient information is established, for effective functioning in society; positive this question will also plague future planning and coping capacities and generalized stress resis- delivery efforts [18]. tance; and availability of networks and positive Health-care planning and policy are moni- community support systems [64, 78]. tored by a diverse array of agencies and community organizations: the Indian Health Service and its advisory committees, tribal health depart- Prevention-Related Considerations ments, the National Indian Health Board and its constituent area offices, the Urban Indian Health In light of the present state of the art, future Care Association, the Bureau of Indian Education, research on and the delivery of prevention 8 American Indian and Alaska Native Mental Health 141 services to American Indian and Alaska Native largest, well-regarded randomized controlled, communities must consider the following American Indian and Alaska Native substance questions: (1) What forms of psychopathology abuse prevention trial evaluated the universal, are thought to be preventable? By Indigenous school-based adaptation of Botvin’s Life Skills means? By nontraditional means? (2) What are Training Program by Schinke et al. [81]. the available techniques? (3) How does one Participants were American Indian elementary appropriately measure outcome? (4) What students grades 3 through 5 representing 27 ele- constitutes effective prevention from a cultural mentary schools. The intervention was found to perspective? (5) To what extent and under what lower rates of alcohol use by 24% and rates of conditions are these techniques differentially marijuana use by 53% than the control schools. effective? (6) How can “mental health” be However, American Indian community interven- sustained and promoted? tion components exerted no helpful influence on participants’ substance use, beyond the impact of skills intervention components alone. The Primary Prevention Efforts Cherokee Talking Circle, school-based drug prevention curriculum, makes use of the Talking Primary prevention seeks to lower the prevalence Circle as its primary means of intervention. of disease by reducing its incidence, which can Using a quasi-experimental design, the Cherokee be accomplished in three ways: health promotion Talking Circle condition was compared to stan- and enhancement, disease/disorder prevention, dard care (i.e., Be a Winner/Drug Abuse and health protection. Health promotion and Resistance Education) to find that the Talking enhancement involve building or augmenting Circle condition yielded greater increases in adaptive strengths, coping resources, survival self-reliance and decreases in substance abuse/ skills, and general health. In addition to focusing use from baseline to posttest [82]. Further work upon the capacity to resist stress, health promotion on the promising programs that have potential and enhancement require an understanding of the for empirical trials needs to be done. Whitbeck conditions that generate stress and that may affect et al. [80] contend that it is an arduous task to psychosocial functioning negatively. Disease/ conduct gold standard trials in American Indians disorder prevention encompasses a much and Alaska Natives communities due to method- narrower spectrum of concerns. It targets a ological tests in developing and implementing specific disorder and, based on an analysis of risk culturally informed prevention efforts (e.g., factors, attempts to manipulate one or more resistance on the part of many Indians and conditions to forestall the occurrence of the Natives to scientific methods, challenges in disease in question. obtaining sufficient sample sizes to detect out- In a 2012 review of American Indians and comes, and challenges in generalizability of the Alaska Natives substance abuse prevention pro- findings given the extreme heterogeneity of grams conducted by Whitbeck et al. [80] noted Indian and Native nations). The current state of rapid development in interventions in the area of the field is promising in terms of range of cultur- substance abuse prevention among American ally informed, effective prevention efforts Indian and Alaska Native communities. They addressing Indian and Native youth alcohol and review three categories of substance abuse pre- other drug use and abuse. However, given the vention programs including published empirical paucity of large scale, long-term efficacy stud- trials, promising interventions in the process of ies, it remains challenging for treatment provid- formal development that have potential for ers to decipher the appropriateness or empirical trials, and innovative American Indian cost-effectiveness of these interventions. and Alaska Native community-driven standard- Early quasi-experimental studies such as the ized compilations that may have promise for evaluation of the Zuni Life Skills Development improvement and wide-scale expansion. The Curriculum provided evidence for prevention 142 J. E. Trimble et al. programs that are grounded in cultural values treatment condition reported larger effects relative and perspectives in reducing suicide among to antisocial personality disorder participants in American Indian adolescents [83]. A recent the control condition [89]. O’Malley et al. [90] quasi-experimental study of the Alaska People studied the efficacy of naltrexone alone and in Awakening Team’s cultural prevention interven- combination with sertraline in a randomized con- tion targeting suicide provides a model for pre- trol trail with Alaska Natives and other Alaskans vention intervention research with small sample living in rural settings. They found that naltrexone sizes [84]. The model testing of the Reasons for can be used effectively to treat alcoholism in that Life and Reflective Processes conducted by the setting with evidence of benefit for Indians and People Awakening Team supports a potential Natives. protective factors model for alcohol abuse and suicide prevention that may generalize to youth from other Alaska Native and other Indigenous Cultural Mental Health Practices groups [85]. of American Indians and Alaska Natives

Secondary Prevention Efforts Earlier we discussed the role Indigenous traditional healers can play in the arrangement and Secondary prevention seeks to reduce the preva- delivery of culturally appropriate and sensitive lence of disease or disorder through early case mental health services. Traditional healing sys- finding and treatment. A reduction in the duration tems are important in the treatment of American of a case consequently decreases the total number Indians and Alaska Natives communities. These of active cases at any given point in time. Manson systems focus on balancing mind, body, and et al. [86] identified the relationships among psy- spirit via a connection with place and land [30]. chophysiological symptoms, Indigenous catego- Some American Indian and Alaska Native popu- ries of illness, and research diagnostic criteria for lations believe that traditional-based healing depression within a southwestern American practices have potential to help address mental Indian tribe, permitting earlier intervention and health-care needs within their communities. more appropriate treatment [87]. To our knowl- Research shows that Indigenous men and women edge there have been no evidence-based evalua- who meet criteria for depression/anxiety or sub- tions of prevention interventions in the area of stance use disorder are significantly more likely depression or anxiety with Indian and Native cli- to seek help from traditional/spiritual healers ents. Much like the explication of primary preven- than from other sources [15, 16]. tion, there are some small-scale efficacy studies to Protective factors are concepts that are key to prevent incidence reoccurrence of depression and the “cultural context, identity, adaptability, and symptoms of PTSD [88]. More recently there perseverance” of American Indians and Alaska have been a few evidence-based studies of the Natives. The factors include holistic approaches effectiveness of interventions for American Indian to life, a desire to promote the well-being of the adults with mental and substance use disorders. In group, an enduring spirit, and respect for all ways a randomized control trial to determine the effi- of healing [17, 18]. Strengths and protective fac- cacy of a DWI intervention program with a pri- tors common to North America’s Indigenous marily American Indian sample, participants who communities include a strong identification with received first offender incarceration and a non- culture, strong family ties, enduring spirit confrontational treatment program reported (persistent, embracing the future, forward greater reductions in alcohol consumption from thinking), connection with the past, traditional baseline levels when compared with participants health practices (e.g., ceremonies), adaptability who were only incarcerated; within this study (flexible), and the wisdom of elders (respect for antisocial personality disorder participants in the knowledge shared and knowledge earned). 8 American Indian and Alaska Native Mental Health 143

As we have indicated in several sections of quests and the interpretation and analysis, revered this chapter, there is an abundance of evidence or in any way expected of an individual. that exists that illustrates the difficulties Mental health and all of its aspects can and experienced by practitioners in delivering mental probably does mean quite different things to health services to American Indian communities many American Indians and Alaska Natives. And [91–94]. While never quite empirically docu- the implication that mental health is grounded in mented, one of the major problem sources could different ways in the value and belief systems of well be the way mental health, in all its facets, is one’s cultural group gives rise to serious questions conceptualized by many American Indians and for cross-cultural studies of American Indian and Alaska Natives. For numerous North American Alaska Native mental health. The efficacy of past Indigenous groups, thoughts, beliefs, ceremonial mental health research efforts must be assessed practices, and traditions, among other ways of with this implication in mind. thinking and living, are holistic. States of mind Numerous American Indian and Alaska Native and body, social roles, family and community mental health practitioners and scholars maintain organization, and the like are functionally inter- that American Indians and Alaska Natives believe related and virtually inseparable. “Mental,” that individuals choose their state of wellness. If “mind,” “personality,” and “self,” for example, one stays in harmony with all that embraces them have unique organizing qualities within the and follows all the tribal and sacred laws, one’s Native view. For this reason, many traditional spirit will be strong, and thus negativity will be Native people experience difficulty coming up unable to influence it. If harmony is broken, the with conceptually equivalent mental health terms spiritual self is weakened, and one becomes in their own native languages. American Indians vulnerable to physical illness, mental and/or and Alaska Natives, like all other linguistic emotional upsets and the disharmony projected groups, developed unique systems for “classifying by others. The “path” or “way of living” provides and categorizing forms of behavior {that} fit the individual with traditionally grounded closely within their world view and the view they directions and guidelines for living a life free of have of themselves as people” [91, p. 14]. emotional turmoil, confusion, animosity, In the Lakota language, for example, “mental unhappiness, poor health, and conflict-ridden health” translates as ta-un (being in a state of interpersonal and intergroup relations. well-being, not a state of well-being). Ta-un is a American Indian and Alaska Native tribes and state of being that allows certain kinds of behav- villages developed and maintained sophisticated ior to occur. One’s ta-un is rarely, if ever, ques- and elaborate systems or collections of principles, tioned; in fact, it’s almost unthinkable to ask beliefs, or practices that guided individuals along someone to elaborate on the state. For that matter, the straight path. Healing practices also were within many segments of the Lakota reservations, well established to assist individuals who strayed it’s considered rude to inquire about a person’s from the “straight path.” Shaman or traditional psychological well-being, no matter what the healers were delegated or inherited by birthright state of may appear to be [91]. While the concept the responsibility to conduct healing ceremonies, of attaining personal insight is important to many and healing traditions were handed down from mental health intervention programs, it could one generation to the next following highly also be another source of difficulty for those regulated rites of transmission, passage, and working with traditional American Indians and protocol. Healing practices as well as the specifics Alaska Natives clients. In many American concerning the “ways of living” no doubt varied Indians and Alaska Natives community’s self- considerably from one tribe or village to another. reflection is just not taught, revered, or in any Moreover, many of these practices likely changed way expected of an individual. Certainly, there over the centuries through exchanges of practices, are ceremonial occasions in many communities rituals, and ceremonies generated by contact with where one reveals the content of dreams or vision other groups and new insights gained by healers 144 J. E. Trimble et al. through personal and spiritual experiences. villages or communities; distrust of traditional Traditional “ways of living” continue to be healers and their practices; lack of access to endorsed and practiced by most North American traditional healers, especially in urban settings; Indians and Alaska Natives, although some vary lack of awareness of the presence and considerably from the ways they were practiced effectiveness of traditional practices; and and carried out centuries ago. confusion concerning the choice between Noisy Hawk and Trimble [95] maintain that traditional healing and use of mental health traditional Lakota’s, well-being (wicozani) is a counselors and clinicians. psychological state of being at peace and harmony Reasons vary from one individual to another. (wolakota) with oneself and with all of creation For those who choose not to seek the services of (mitakuye oyasin); the good happy life [96]. The traditional Native healers, the only available lack of harmony and well-being or lack of success alternative is to seek the assistance of in American Indians and Alaska Natives professionals in the conventional mental health counseling strategies could be improved by more fields; that choice, too, can be compounded by research to discern how American Indians and numerous factors, including distrust, Alaska Natives conceptualize and process misunderstanding, apprehension, and the real cultural determinants of psychological illness possibility that mental health practitioners may and wellness and by incorporating aspects of the be insensitive to the cultural backgrounds, traditional understanding, such as the Lakota worldviews, and historical experiences of path to well-being. Well-being for American American Indians and Alaska Natives clients. Indians and Alaska Natives should be The main issues for these clients are concerns strengthened by providing a cultural context for that their “presenting problems” may be distorted healing programs and research that incorporates by the results of psychological tests that are and emphasizes the importance of language, incongruent with their cultural worldviews and mythology, and ritual. Those components of a that professionals may arrive at clinical diagnoses culturally specific context mediate the self- grounded in psychological theories that do not identification of the path to healing/well-being. value and consider culturally unique perspectives. Many American Indians and Alaska Natives traditional healers have identified well-being as the result of living in context with cultural laws, Summary and Conclusion family, and the tribe [97]. For modern observers to assume or claim that There have been several national task forces that mental health healing practices are new to have specifically addressed the mental health of American Indians and Alaska Natives would be American Indians and Alaska Natives. Among presumptuous. In one form or another, healing them are the President’s Commission on Mental those who stray from the straight path has always Health (PCMH) in 1978; Manson’s [75] supple- been a part of the holistic fabric of the lifeways mental report of the US Surgeon General; and the and thoughtways of Indigenous peoples. Most 2011 report by the Office of the Inspector American Indians and Alaska Natives know General. Many of the questions posed in this something about contemporary versions of these article echo the recommendations of those practices. However, not all American Indians and reports. Those recommendations note that “at Alaska Natives choose or have the opportunity to present services and service delivery systems to participate in them, owing to a number of factors, (American Indian and Alaska Native) people ... including orthodox religious convictions (or are disjointed, disorganized, wasteful, frag- conversion) marked by conformity to doctrines mented, and counterproductive” [88, p. 982] and or practices held as right or true by some call for an examination of ways in which to coor- authority, standard, or tradition; geographic dinate the delivery of mental health care more distance of traditional healers from their home effectively. 8 American Indian and Alaska Native Mental Health 145

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Imad Melhem, Zeina Chemali, and Ashlee Wolfgang

Introduction Iraqis, Jordanians, Palestinians, or Arabs from North African countries), and there are Muslims The Middle East is a geographical location who are not Arabs (such as Turks and Pakistanis). spreading between Southwest Asia, North Africa, Immigrants from the Middle East constitute the and Europe. With the exception of Iran and Israel, highest proportion of migrants worldwide [1]. the countries forming this region are all Arab and Immigrants also include refugees who were forced are frequently referred to as the “Arab world.” to leave their country in order to escape war, perse- The Arab world is comprised of 22 countries cution, or natural disaster. Despite their significant including Iraq, Syria, Lebanon, Jordan, the West racial and ethnic heterogeneity, these immigrants Bank and occupied territories (Palestine), and all may share a similar experience of migration and the Gulf states. In addition, it extends through acculturation process when they arrive to the North Africa to Egypt, Algeria, Tunisia, Morocco, United States. The first wave of immigrants primar- Libya as well as Sudan and parts of Mauritania. ily left their countries in search of education, eco- Arab countries are diverse in size, political nomic opportunities, and freedom. More recently systems, and religions. Contrary to a common and with an increased numbers of refugees, they misperception, being Arab is not synonymous to are seen fleeing political oppression and war. being Muslim. Rather, there are Arabs who are Arab individuals share multiple similarities not Muslim (such as some Lebanese, Syrians, though they may differ in their origin: Semite people (descendants of Abraham), Shami people (Lebanon, Syria, Jordan, and Palestine), Arabs I. Melhem (*) from the Gulf states (United Arab Emirates, Neurobehavioral Medicine Consultants, Saint Clairsville, OH, USA Kuwait, Yemen, Bahrain, and Saudi Arabia) or e-mail: [email protected] North African Arabs. Intra-ethnic diversity covers Z. Chemali a spectrum from the most religious to the most Division of Global Psychiatry, Department of secular and political systems of governance vary Neurology and Psychiatry, Massachusetts General between democratic, monarchal, dictatorial, or Hospital-Harvard Medical School, Boston, MA, USA tribal. Even though language is the main common- e-mail: [email protected] ality between the different Arab populations, it is A. Wolfgang not the only one. They share common food, music, Counseling and Psychological Services, Carnegie Mellon University, Pittsburgh, PA, USA literature, holidays, traditional events, and political e-mail: [email protected] histories [2]. Despite receiving significant public

© Springer Nature Switzerland AG 2019 149 R. Parekh, N.-H. T. Trinh (eds.), The Massachusetts General Hospital Textbook on Diversity and Cultural Sensitivity in Mental Health, Current Clinical Psychiatry, https://doi.org/10.1007/978-3-030-20174-6_9 150 I. Melhem et al. attention since the September 11, 2001 terrorist same token, shed some light on the many attacks on the United States (9/11), Middle Eastern challenges such work poses to the professional of populations remain a poorly understood group. similar background as well. It is also vital for Many Americans may only be informed about the mental health professionals to acknowledge the Middle Eastern culture through public media many overlapping identities of a single individual [3–5]. and the impact on psychological functioning and The interaction between an individual’s and a navigation of the social and political world. The provider’s cultural background plays a major intersections of race, culture, gender, religion, role in the patient’s symptom expression and and sexual identity are discussed throughout with adherence to treatment [6]. Mental health ser- awareness of how this can influence the Arab vices in the United States are frequently under- American experience of discrimination and utilized by immigrant populations [7–9]. This is oppression. partly caused by a lack of cultural sensitivity toward the patient [2, 10]. Professionals working with people of Arab origins may find only Arab Americans limited data to guide their understanding and treatment of the mental health problems of this Social Demographics population [11, 12]. Empirical research addressing the mental health of Arab Americans has Data collected for the 2010 US Census estimate been largely explorative in nature and remains the number of Arab Americans to be around 1.9 negligible compared to that involving other US million people. This number is likely to be minority groups [1, 13]. A deficient understand- inaccurate due to significant underreporting. ing of the cultural and mental health correlates Arab Americans have often been designated as of this population may push professionals to an “invisible minority.” Identification biases rely on the only other available information occur when Arab Americans identify them- source that is mainstream politicized media selves as Middle Eastern or as Caucasian, thus [14]. This is especially true given the increased leading to difficulty in estimating their exact discrimination this community was subjected to numbers. This is interpreted to be partly caused after 9/11 [15]. As a result, these professionals by fear of misperception or distrust in surveys are predisposed not only to stereotyping and [16]. The Arab American Institute generates a prejudice but also to inaccurate diagnosis and number closer to 3.6 million when accounting treatment [14]. for such underreporting errors [17] (Table 9.1). This chapter aims to provide clinicians, edu- Approximately two-thirds of Arab Americans cators, and professionals with a better under- were born in the United States, and around 82% standing of this community. It begins with a of them are US citizens [12]. When the US sociodemographic overview of Arab Americans Census started collecting data related to Arab and their immigration patterns followed by a ancestry in 1980, the number of Arab Americans review of the characteristics of their mental in the United States had grown by more than health. It then presents the cultural considerations 70% by 2010 [17]. Arab Americans are distrib- pertinent to a culturally sensitive understanding uted all over the United States, but the majority of this population. Blended case vignettes are live in one of these ten states: California, used to illustrate the cultural complexity Michigan, New York, Texas, New Jersey, encountered in the clinical setting. Finally, the Illinois, Ohio, Pennsylvania, Virginia, and chapter concludes with clinical recommendations Florida. About one-third of this population set- to the professional treating Arab Americans. It is tled in metropolitan cities of Detroit, Los hoped that this body of work can in itself foster Angeles, and New York. cultural sensitivity in clinicians and professionals The majority of the Arab American commu- who are not Arab or Middle Eastern and, by the nity claim Lebanese or Syrian origins [17]. 9 Mental Health of Arab Americans: Cultural Considerations for Excellence of Care 151

Table 9.1 Demographic description of Arab Americans Ancestry Population Percent of Arab American population Percent of US population Arab countries Overall Arab 1,646,371a 100 0.53 Egyptian 190,078 11.55 0.06 Jordanian 61,664 3.75 0.02 Iraqi 105,981 6.44 0.03 Lebanese 501,988 30.51 0.16 Moroccan 82,073 4.99 0.03 Palestinian 93,438 5.68 0.03 Araba 290,893 17.67 0.09 Other Arab 223,020 13.55 0.07 United States, overall 309,349,689 Source: American Community Survey (2010) (US Census Bureau) aIndividuals who marked their ancestry as Arab without specifying a country of origin

However, immigrants originating from Egypt Arab Immigration Patterns and Iraq have witnessed the sharpest increase in to the United States number since 1990 [17]. Further data about specific ancestry may be missing as many census The migration patterns of Arab populations to the respondents (approximately 17%) mark the gen- United States are historically divided into three eral category of “Arab” or “Arabic” to describe phases referred to as “waves of immigration.” their roots [17]. Between half to two-thirds of These waves differ from one another in historical Arab Americans self-identify as Christians and political circumstances, demographic (Roman Catholic, Eastern Orthodox, and distribution, and the acculturation processes of Protestant in descending order); the rest are the immigrants [12]. The first wave started around Muslims in majority [1, 18]. However, in recent 1875 and lasted until World War I. The majority years, Arab Muslims became one of the most of these immigrants originated from Syria and rapidly growing populations in the United States Lebanon. They were mostly Christians who [1]. This is due in part to the United States worked in farming and trade and left their Refugee Admissions Program (USRAP). Since countries under the pressure of economic 2007, USRAP has helped with resettling more hardship [21]. than 60,000 Iraqi refugees in to the United States The second wave spread between 1948, the [1]. In the United States, Islam ranks as the sec- year the state of Israel was established, and the ond religion in number and as the fastest grow- 1967 War between the Arabs and Israel. As ing religion in the country [19] and in the world compared to the first wave of immigrants, this with around 1.57 billion believers [20]. The group was more educated, spoke English more number of Muslims in the United States is esti- fluently, and pursued higher education and mated to be around 7–10 million [19]. professional occupations. The second wave In 2011, Arab Americans were found to be immigrants left their countries at a time when the comparatively younger, wealthier, and more Arab world was gaining its freedom from the educated than the national average [1]. The European colonies and were more attached to majority are entrepreneurs and owners of their Arab identity [12, 22, 23]. Demographically, businesses [14]. Newly arriving Arab immigrants this wave had a higher proportion of Muslims and refugees leaving war-torn areas of the Middle than the first wave [11]. During these first two East generally have a lower socioeconomic waves, Arab immigrants settled in the Northeast status. Many of them are living below the poverty and Midwestern cities like Chicago (Illinois), line, tend to have a lower level of education, and Dearborn and Detroit (Michigan), and Toledo do not speak English [1]. (Ohio) [24]. 152 I. Melhem et al.

A third wave of Arabs started migrating to the by colleagues in the fields of sociology, nursing, United States after 1967 and continues until the and anthropology [14]. These studies identify present day. This wave is largely comprised of important basic sociodemographic characteristics Muslim Arabs and is characterized by a diverse of the populations but are largely qualitative in mix of educational and socioeconomic levels nature or based on small sample surveys [13, 14]. [14]. The vast majority are fleeing war or unstable Most studies continue to investigate these political conditions and are looking for economic characteristics in community settings and in opportunities [12, 23]. During the 1990s, the chronic diseases (e.g., hypertension, diabetes number of Arab immigrants from North Africa mellitus, and heart disease) [19, 34]. Limited and the Gulf states grew significantly [21, 25– research on this population constitutes a major 27]. Multiple waves of Iraqi refugees migrated hindrance for a provider’s ability to meet its during and after the Gulf War of 1991 [28]. These rising mental health needs [35]. refugees settled mostly in the metropolitan Only few clinical studies have examined risk Detroit area of Michigan where a large Arab factors and the mental health concerns of Arab community was already established [29]. Americans, especially in the period following In Arab countries with devastating war con- 9/11 [13]. One study identified increased rates of flict such as Syria and Yemen, migration to the depression and posttraumatic stress disorder United States has drastically increased since (PTSD) among Arab Americans as compared to 2010. The United States resettled more than the community [36]. Another study involving a 18,000 Syrian refugees since the start of the sample of Muslim Americans, among which 44% Syrian Civil War in 2011. Acceptance of Yemeni were of Arab origins, documented an association refugees has been much lower with just over 60 between perceived religious discrimination and refugees accepted between 2011 and 2016 [30]. subclinical paranoia [37]. A study by Amer and At the start of 2017, rates of immigration from Hovey showed that Arab Americans display the Middle East and North Africa shifted when higher rates of anxiety and depression compared the Trump administration enacted sweeping pol- to nonclinical community samples (normative icy change, including a temporary sanction that samples) (pp. 409–418) [13]. Another study disallowed individuals from Iran, Libya, Somalia, examining suicide among Arab Americans living Sudan, Syria, and Yemen from entering the in Michigan (MI) found lower suicide rates United States [31]. The ceiling for refugee admis- among this population when compared to non- sions was also dropped from 110,000 to 50,000 in ethnic Whites, regardless of gender [15]. Arab 2017. Overall, approximately 54,000 refugees Americans in Wayne County, MI, where the from all countries were resettled in the United largest Arab community resides, also had lower States in 2017, compared to 86,000 in 2016. suicide rates than Arab Americans outside of this Syrian refugee resettlements decreased from county [15]. These outcomes parallel findings 15,500 in 2016 to approximately 3000 in 2017, a among other ethnic minorities, where a collective near 80% reduction [32]. mentality, familial and cultural social bonds, and group and community identity are strong protective factors against suicide [15]. Mental Health of Arab Americans Many factors likely attribute to the small amount of research within the Arab American Research population. Arab Americans, frequently referred to as an “invisible minority,” are often merged in Empirical research on the status of Arab American public surveys with “White” or “Caucasian,” and mental health remains minimal. Studies many may refrain from identifying themselves as examining the mental health of minorities rarely Arabs [13]. In conducting research studies, this include Arab Americans as a subgroup [13, 29, can prohibit appropriate random sampling from 33]. Most available studies have been conducted public mental health databases [13]. Furthermore, 9 Mental Health of Arab Americans: Cultural Considerations for Excellence of Care 153 the dispersion of this population and their small After much resistance to the idea, Rania numbers in certain states makes it hard to reach started treatment with at an outpatient psychiatric sufficient samples for such studies [13]. Another clinic. She was on time to each of her appointments major factor is a common aversion among Arabs and always dressed in traditional Muslim to written surveys due to a mistrust of research clothing, including the hijab. Initially, she and its purposes [14, 16]. In addition, many displayed significant preoccupation with her research tools and measurement scales lack health and required frequent reassurance. Early cultural sensitivity and validity for the Arab sessions stressed the connection between her American population, presenting another major physical symptoms and feelings of anxiety. Over obstacle for obtaining reliable outcomes [13]. the next few months of her treatment, Rania Finally, mental health symptoms in Arab shared more information about her cultural Americans may be disguised under somatic background and family. She expressed frustration complaints and when acknowledged as with her teenage daughter, who liked to listen to psychiatric symptoms (e.g., depression) may be American music, refused to do her chores, and defined differently, rendering the task of insisted on going out every day. She also talked researchers more challenging [28]. about the lack of intimacy with her husband. She described him as a kind and supportive man, yet felt rejected by him, as he would visit her only Cultural Display of Symptoms after an episode. Rania discussed feelings of loneliness, her family of origin, the growing Case Vignette 1 independence of her children, and the advice of her local Egyptian community to stay at home 55-Year-Old Female With Paroxysmal more often. Episodes of Body Shaking As psychotherapy progressed, Rania acknowl- Rania, a 55-year-old Egyptian female, migrated edged her anxiety and depression but refused to to the United States 6 years ago with hopes of take psychotropic medications. Her treatment ensuring a better future for her children. She consisted mainly of cognitive behavioral modali- married her husband, 20 years older than her, in ties to identify her anxiety triggers. She was also her late 20s. He remained in Egypt. They had five introduced to relaxation techniques and cognitive children. Four of them were already studying in restructuring to help her divert her attention from American colleges and one teenage daughter was negative thoughts. With time, Rania was able to still living at home. Rania had studied to be an speak more openly about her feelings and her engineer in Egypt, but her degree did not allow episodes began to lessen. She joined a vocational her to work in the United States. rehabilitation program to prepare her for work in Rania was first brought to an Emergency the community. She began taking classes at the Department (ED) by her eldest son for concerns local university and joined a gym. She had 1 year about sudden-onset episodes of body shaking and free of any episodes or anxiety symptoms until severe weakness that at times she could not stand the 2013 Boston Marathon bombing. This trig- up. She often experienced intense fear that these gered daily panic attacks. She collapsed while at episodes would occur while in public. These the gym, and she had to be transported to the ED, periods of weakness and fear resulted in multiple where the medical work-up was once again nega- visits to the ED, where all cardiac and neurologi- tive. In session, Rania verbalized fear of discrim- cal testing revealed no abnormalities. She had no ination as a Muslim woman wearing a head veil. psychiatric or neurological history prior to visit- She also feared that her college-age daughter, ing the psychiatric clinic. Her symptoms had who also wore a headscarf, would be assaulted on been occurring over a period of 6 months after campus. She felt people were looking at her in a which it was concluded that she be referred to a “funny way” and suffered from disrupted sleep. mental health professional. As a result, her therapy sessions were increased 154 I. Melhem et al. to biweekly appointments to continue to address a sense of chest oppression or shortness of breath her recurring anxiety symptoms. She established [42]. In addition, given the religious prohibition a new goal of traveling to Cairo in the fall to visit of suicide in traditional Middle Eastern cultures her sisters and finish her vocational rehabilitation (both Christian and Muslim denominations), and program. (end of case vignette 1). for fear of being refused burial, patients may Immigrants’ perceptions of their experience refrain from sharing suicidal ideation with the and adjustment to illness depend on their cultural mental health provider [40]. Another obstacle to view of disease and their expectations of health symptom disclosure is that many Arab Americans services [3]. An Arab American patient may consider the discussion of family matters with a display psychiatric symptoms differently than a stranger (i.e., the provider) a cultural taboo [40]. Western patient. Arab Americans tend to express They may refuse to answer probing questions or psychological pain through physical symptoms simply dismiss discomforting topics as normal. or by using somatic terminology [38] like Rania Along the same logic, religious teachings forbid- in the above case. A fatalistic worldview ding gender interaction (in Islam) and premarital predominates the cultural thinking with a sexual intercourse may prevent the patient from significant reliance on God’s will exemplified by admitting to an active sexual history or sexual the famous insha’Allah (God willing) [39]. In assault [40]. In the Arab culture, the concept of addition, many regard envy or “the evil eye,” “bizarre” that applies to certain psychotic symp- referred to as hasad in Arabic, as a main cause of toms may be different from what Western pro- ailment [1]. This concept may be mistakenly viders are familiar with. For example, psychotic understood as a delusion of persecution in delusions may frequently be expressed in reli- Western culture. gious or political contexts pertaining to the The application of the Diagnostic and native country. Differentiating between delu- Statistical Manual of Mental Disorders, 5th sional thought content and non-delusional cul- Edition (DSM-5) criteria and its subsection on tural beliefs is critical in avoiding misdiagnoses. culturally bound syndromes, is often not readily Negative symptoms of schizophrenia could eas- applicable to Arab Americans [40]. Clinicians ily be misinterpreted as a deficit in English lan- report a high frequency of somatic symptoms in guage proficiency. As a result, when attempting this population. Reporting physical complaint as to diagnose psychiatric disorders in Arab a substitute for low mood or anxiety symptoms Americans, familiarity with the patient’s culture may be due in part to stigma and shame associated and country of origin as well as culturally sensi- with having a psychiatric diagnosis [29]. In tive and Arabic-proficient interpreters prove crit- addition, it may be that the Arabic language ical in arriving at the correct diagnosis and allows for a different description of pain and treatment recommendations. makes a clear distinction between physical and psychological pain [41]. These factors emphasize the challenges men- Alternative Cultural Practice, tal health professionals may face when attempt- Traditional Healers ing to understand symptoms using the DSM-5 [40]. For instance, when it comes to mood disor- In Arab societies, traditional healing is used in ders, Arab American patients often perceive parallel or at times before accessing mental them as physical in nature. Negative feelings and health services [11]. These methods are viewed internal or external conflicts are not expressed as complimentary rather than oppositional. with much ease. Instead, somatic symptoms are Hence, it is not unusual for the individual to seek the more acceptable form of expression. Anxiety both types of treatment simultaneously [11]. or depression may be expressed as gastrointesti- By definition, the traditional healer or Hakim nal complaints, bodily pain, or fatigue [38]. They (Arabic for “wise”) emphasizes the spiritual- can be expressed as “thinking too much” [11] or mental portion of treatment. Typically a male, he 9 Mental Health of Arab Americans: Cultural Considerations for Excellence of Care 155 is regarded as an authoritarian figure whose pres- Underutilization of Mental Health ence is central to the treatment and healing pro- Resources cess. He guides, instructs, and provides the patient with a treatment plan and may suggest ritualistic The utilization of mental health services by techniques, such as burning incense or visiting the immigrants may be significantly affected by tombs of saints [11]. The traditional healer is also cultural and immigration-related issues [7–9]. Of seen as a father figure who provides support and note, the trauma-related history of most refugees validation [11] and maintains a close connection resettled in the United States makes utilization of with the patient. Contrary to modern mental mental health services even more problematic. health services, which may lack collaboration These patients may show up to emergency wards with the patient’s family [43], traditional healers with somatic complaints rather than mental actively engage the family. They identify and health symptoms and may not share their trau- include a member who holds a dominant presence matic experiences. The younger generation of in the patient’s family to facilitate the process of refugees may be more likely to recount what they treatment and the recruitment of family and com- witnessed, and their trauma issues may be dealt munity resources in that process [11]. with in the offices of mental health professionals In addition, traditional healers also exist in the or captured by mental health services and Islamic religion. For Muslim Arab Americans, community resources. this approach is sometimes used at least in the Underutilization of psychiatric resources and primary phase of treatment. Few commonly used services may exist in Arab Americans to the same figures are the Katib, the Moalj belKoran, and the extent it does in the Arab world [11, 46]. Multiple Dervish, who aim to deflect evil spirits or prevent factors may be responsible for such reluctance. illness. The Katib, also referred to as Hajjab who Arab Americans, similar to other non-Western is a typically a male, creates amulets for the cultures, often perceive mental health services as patients to wear on their body. The Moalj stigmatizing [47]. Seeking psychiatric care is a belKoran (or the healer through Koran), also a last resort. Stigma causes significant emotional male, uses the Koran and Islamic scripture [44, distress to the patient who may fear being labeled 45]. The dervish can be a male or a female and as “crazy” (majnun in Arabic) if they sought men- uses cultural or religious techniques for the tal health assistance [38]. The notion of “lunatic treatment of mental illness [11]. house” or “nut house” is pervasive. In addition, The use of traditional healers by Arab Arab Americans may have a general disbelief in Americans remains the exception rather than the the benefits of mental health services. Even after rule. Most Arab Americans from various religious agreeing that it is needed, the patient often comes backgrounds rely more on Western medical unprepared to their psychiatric encounter. This approaches as a first line of treatment, even in understanding differs among the diverse immi- cases where the expression of symptoms is primi- grant populations depending on their cultural tive such as acting out or through somatization. backgrounds and the availability of mental health When working with Arab Americans, health- services in their native country [3]. A shortage in care providers and especially mental health pro- mental health services in the country of origin can fessionals should become familiar with the role of result in a deficient perception of the need to seek traditional healers in the treatment process, in the professional help [3]. recovery period, and in the pursuit of well-being. A major hindrance to seeking help comes The traditional healer shares a similar background from the discomfort an Arab American may have with the patient and hence a relatively closer with discussing personal issues or feelings of worldview and can assist as an important facilita- weakness with a non-family member [12]. This tor of the patient’s grasp of their problem, its may also be due to the threat such an act can pose sources, and appropriate ways to manage it [11]. to the person’s sense of loyalty or the dishonor it may bring to the patient’s family [48]. Instead of 156 I. Melhem et al. seeking professional help, an Arab American health education aids, and culturally sensitive may seek psychological comfort from a family services cannot be stressed enough. member, typically of the same gender [3]. This As for inpatient hospital stays, the Arab patient tendency is augmented by a general distrust of may become uncomfortable or even agitated in non-Arab health providers although it could be wards where men and women share hallways or seen for the same reasons with Arab-speaking units in the hospital. Hence, the treatment plan providers as well [12]. should reflect such dynamics. A general unfamiliarity with Western psycho- After the events of 9/11, an added barrier to logical models and ways to access such services medical care surfaced among some Arabs in the may be prevalent among Arab Americans [3]. United States [1]. The mistrust in government Arab Americans expect mental health treatment agencies and fear of deportation may have spread to be timely, structured, and directive with mini- to the field of healthcare where some Arab mal participation on their part, similar to medical immigrants would stay away from any public treatments [11]. They prefer a quick fix and may service that could be connected to the US often expect a “cure” without sharing much per- government [1]. The recent US travel ban on sonal information [11]. Kulwicki explained this certain Muslim countries may also negatively phenomenon: “Arab-American clients often affect the likelihood of Arab Americans to present expect doctors to make medical decisions with- to medical care due to fear of deportation. Many out the need for the collection of a medical his- may prefer to discuss their health issues verbally tory and without consultation with the clients. In and may avoid filling out intake forms for fear cases where the clients are asked to participate in that this information could be used against them decision making about their medical regimen, [19]. Arab American patients may be more likely they may lose trust in the medical experts and to seek mental health services if offered discontinue treatment” (p. 201) [11]. When added reassurance about the confidentiality binding to the cost of services, the lack of insurance cov- their relationship with the provider and the erage, and little awareness of community mental validation of their experience [24]. health care clinics, these factors lower the probability of Arab Americans utilizing mental health services they may need [3]. In addition, Arab The Case of Iraqi Refugees Americans may assume that invasive methods of in the United States treatment such as injections or surgeries are more effective or potent than other treatments. Hence, Case Vignettes 2 Arab Americans may see treatment modalities such as occupational therapy or physical therapy 45-Year-Old Iraqi Male With Posttraumatic as ineffective. This may be even more of a prob- Stress Disorder lem in the case of psychiatric or psychological Khalil is a 45-year-old Iraqi man who was treatments when “talk” therapy is initiated and no referred by his previous provider to see an Arabic- hands-on treatment is perceived. speaking male psychiatrist. He migrated to the Language barriers constitute another signifi- United States as a refugee from Iraq in 2005 and cant obstacle [1]. In the absence of Arabic- currently lives with his wife, two children, and speaking health professionals, interpreters, or his parents in a city with a large Arab community. Arabic-language health materials, accurate He had attended only a few sessions with his symptom description is limited. As a result, the previous psychiatrist after which he started creation, discussion, and implementation of a missing his appointments repetitively. He had treatment plan may become difficult [1]. The requested to see a male mental health professional need for Arabic-language medical interpreters, as he felt embarrassed to share his full story with a female provider. 9 Mental Health of Arab Americans: Cultural Considerations for Excellence of Care 157

During the initial assessment, Khalil stated league psychiatrist for similar problems. (end of that he was considered by his family to be “weak” case vignette 2). for consulting a mental health professional. He Multiple pre-migration and post-migration was unemployed and had trouble finding a job. stressors play a role in the heightened stress and Prior to his migration to the United States, he resulting medical and psychiatric morbidity [29]. worked as an accountant in a governmental The mental health of immigrants is heavily organization. His family, who always influenced by these stressors [49]. Loss and accompanied him to his appointments, traumatic exposure preceding migration represent corroborated a history of physical torture and a risk to the development of mental health multiple traumatic events experienced during the difficulties, and both predict difficulties with Gulf War including witnessing his brother dying adjustment [3]. This is especially true for in a car explosion. Khalil’s parents reported that refugees, like Khalil in the above case vignette, he has been staying at home and not interacting whose migration was forced by war, torture, and much with them or Arab friends. In Iraq, he had persecution [7]. Emotional hardship in been to multiple traditional healers with no immigrants was found to be significantly benefit. He had also worked with the Imam in predicted by prior trauma, torture, pain, lower their community, which helped only minimally. educational levels, a poor social network, and This led to his first referral to a psychiatrist. unemployment [50]. When compared to citizens In the first phase of treatment with the psy- of the country of resettlement, refugees are found chiatrist, much time was spent on strengthening to be ten times more likely to develop PTSD [51]. the therapeutic alliance and a trusting relation- In the post-migration stage, mental health ship with Khalil and his family. In the following difficulties of immigrants have been found to be sessions, Khalil was gently encouraged to elabo- associated with poor knowledge of the English rate on his traumatic experiences, and more language, lower socioeconomic level, and poor symptoms were identified, leading to a diagnosis grasp of the new societal norms [49]. Furthermore, of posttraumatic stress disorder (PTSD). this population has additional burdens that After an initial refusal to take psychotropic prevent their access to healthcare among which medications, Khalil eventually accepted this are the lack of health insurance, working in option after consulting with his parents and other poorly reimbursed jobs, and the absence of family members. Over the following months, he financial support for medical expenses [1]. reported improvement in his symptoms. He started Few clinical studies have examined the mental leaving his house more often and interacting with health of Iraqi refugees. Iraqi immigrants express Arab friends in his community. After 8 months of a different pattern of medical and psychiatric therapy, he began to work as an Arab language illness compared to other Arab Americans [29]. teacher for some of the children of Arab American They are more likely to have general health issues friends and took English language lessons. when compared to other Arab subgroups [29], in During the sessions, open-ended questions addition to a higher prevalence of PTSD, anxiety, were used and medical jargon was avoided. and depression [52]. Substance use disorders Khalil was given ample time to answer. His (SUD) are relatively elevated in this population parents were invited to the sessions on a regular despite their relative rare occurrence in basis. His migration-related challenges and polit- individuals of Arab origins [29]. The wave of ical views were explored. Iraqi refugees who arrived to the United States in Three years later, Khalil continues to report the early 1990s had significant wartime traumatic improvement in his PTSD symptoms. He has exposures from the Iraq-Iran War in the 1980s become more proficient in English and is seeking and the Gulf War of 1991 [29]. Many of these another job. His father started seeing an Arab col- refugees suffered exposure to combat, unsanitary refugee camps, nutritional deprivation, and lack 158 I. Melhem et al. of clean water. Others have experienced multiple Language separations or losses, and some have witnessed the death and maltreatment of their close relatives Arabic is the spoken language and is considered or friends [29]. Others were themselves victims the official language of all 22 Arabic countries. of torture. Since 2007, the US Refugee Arabic ranks fourth among the most widely Admissions Program (USRAP) has helped with spoken languages of the world [18]. Multiple resettling more than 60,000 Iraqi refugees into dialects exist in the Arabic language, and they the United States [1]. Resettlement to Michigan differ vastly from one another and from formal or was officially halted by USRAP following the classical Arabic [59]. Classical Arabic is the decline in its automobile-based economy [1]. As written version of the language and is uniform a result, this population experienced a significant across all countries [18]. In the Arabic language, rise in unemployment rates reaching three times the content is as important as the tonality. For the national average, and many refugees were example, to emphasize something or express a reported to leave the United States to other feeling, Arabs may use repetitions, metaphors, countries [1]. The impact that these factors have exaggeration, euphemisms, and even threats on the mental health of Iraqi refugees and that of (when angry) [18]. Most of the newly arriving the process of acculturation necessitate additional Arab immigrants and especially refugees speak research [29]. Arabic only or are not proficient in English [1]. This was found to be the case in refugee women who frequently had less education than men in Cultural Considerations their native country [1]. in the Mental Health of Arab Verbal communication plays a vital role in Americans achieving a successful therapeutic relationship. The language barrier is one stressful element to A cultural mental health formulation necessi- overcome in the acculturation process. It governs tates a thorough assessment of the cultural val- well-being. It can also impede access to optimal ues of the individual, their religious beliefs, and medical care [1] due to the deficit in communica- the circumstances surrounding their migration tion between the patients and their providers. The and acculturation to the new society [11, 12, 14, lack of proficiency in English in Arab immigrants 48, 53, 54]. There has been a recent increase in may hinder their description of symptoms or their the body of literature by both Arab and non-Arab understanding of their treatment recommendations authors covering the issue of cultural sensitivity potentially leading to suboptimal treatment [1]. when treating people of Arab origin [11, 55]. The availability of medical interpreters and Arabic- Some authors have shed light on the extent of speaking providers is not always an option. As a applicability of Western psychiatric methods and result, many of the Arab patients rely on relatives concepts of mental illness on minority popula- or friends for translation [1], which can have sig- tions in general and women in particular [56]. nificant drawbacks given the potential for family Individual dynamics are connected to sociopo- and control dynamics to interfere with the accu- litical and cultural contexts, and the level of racy of translation or simply the lack of medical acculturation can be very different even between knowledge of these substitute interpreters. members of the same family [56, 57]. Family Given the importance of language in the ther- and couple’s dynamics may mirror government apeutic intervention in mental health, the access and political regime problems. For example, vio- to certified interpreter services or mental health lence may trickle down from authoritarian providers who speak the immigrant’s language is regimes to family, head of households, and cou- of prime importance in the provision of cultur- ple’s dynamics in certain populations [58]. ally sensitive services to Arab immigrants [1, 3]. Health professionals caution that Arab patients Having a family member translate during the may only be fully understood if these contexts session is often counterproductive to the thera- are considered. peutic process. 9 Mental Health of Arab Americans: Cultural Considerations for Excellence of Care 159

Family pretend ignorance of the severity of the illness to spare their family the distress and emotional In the Arab culture, the family constitutes the pain. core organizational structure of the individual It is important to note that the above family and group identity [3]. Individuals are frequently practices are less and less valued by younger referred to by an alternate name underlining their generations of Arab Americans creating a family affiliation. A designation such as Ibn (the significant intergenerational stress [3]. In contrast son of …) preceding the name of the individual’s to their parents, younger Arab Americans may father or family name is used. Another common tend to distance themselves from their native designation is Abu (the father of…) followed by culture. Urbanization has also had a major impact the name of the oldest son of the person. Due to on the Arab family and their cultural idioms. For this strong affiliation with family, Arab Americans example, younger Arab Americans may be rushed may present initially as reserved when interacting for time, for money, and for delivering care to with people outside of their networks and as a their children. They find themselves struggling result building trust with them may take more between caring for their elder parents as their time [41]. The Arab American individuals may be culture dictates while providing for their own more invested in the family identity than their children. individual happiness and personal needs. The level of involvement of Arab patients with The extended family is also a larger social net- their families may be a source of indecision and work that plays an important role in the Arab’s guilt for fear of disappointment of the family everyday life. It is not unusual to see many [29]. When working with an Arab American, the generations of the same family living in the same mental health provider should take into residence or close to one another [12]. In the consideration that emphasizing individuation country of origin, extended family members help does not necessarily serve the treatment objectives with housework, child care, and parenting [40]. [18]. An alternative would be to understand the This network is significant in major crises or individual within the group and allow for systems events, helps the sick members of the family, and remediation. can provide emotional and economic support [18]. Arab American will always go to a family member when in need for emotional and financial Gender support and even advice. They may show discomfort in discussing personal issues with a Case Vignette 3 non-family member. This may be due to the potential threat such an act could pose to the 30-Year-Old Moroccan Woman person’s sense of loyalty or the dishonor it may With a History of Domestic Violence bring to his or her family [44]. Instead of seeking Lamia is a 30-year-old Moroccan-American professional help, an Arab American may seek woman of Muslim faith. She spent the majority psychological comfort from a family member, of her life living in Morocco before moving to the typically of the same gender [2]. For the Arab United States. As the oldest of four girls, she patient, family members would typically assist played a significant role in helping to raise her throughout the help-seeking process and the sisters from a very young age. She married a choice of treatment approaches [11]. Family Moroccan man soon after finishing high school members may even interfere with the disclosure in an arranged marriage. Lamia had three chil- of medical information to the patient. This is dren with her husband, a son and two daughters. especially true in the case of severe or terminal Two years ago, Lamia was referred to a mental illnesses such as cancer. The family may ask the health clinic after a significant history of domestic treating team not to inform the patient of their violence perpetrated by her Moroccan husband. diagnosis for fear of the patient “losing hope.” On She had filed for divorce, and a restraining order the other hand, the patient may sometimes was already in place at the time of her referral. 160 I. Melhem et al.

Upon meeting with the mental health profes- as a free woman. Lamia’s adjustment to American sional, Lamia expressed great fear of her hus- society was explored. Most importantly, she was band, describing her struggle as “fighting an evil helped in maintaining a balance between her indi- man.” She reported severe bouts of depression vidual goals and upholding her culture and stemming from years of trauma and discord Muslim faith. In her work with other Arab within her family. She revealed a life that had American women, the mental health professional been full of threats, violence, male privilege, and avoided the generalization from Lamia’s case and entitlement. She expressed much disappointment the common stereotype of Arab women being that her family no longer held respect for her oppressed. (end of case vignette 3). despite all she had done to care for them. More Among Arabic countries, gender roles differ than once, Lamia had to make the difficult choice widely. Women in Lebanon and the West Bank to openly defy her family’s wishes. Discussing may be highly educated and secular, drive cars, the subject of divorce with her parents often conduct business, and wear Western dress. resulted in insults and threats. She was denied Women in the Gulf may practice few of those attention and affection and was judged by her activities and may be completely covered by a family to be a “loose” woman. burka or a chador. In either place, women are Throughout treatment, Lamia described con- expected to get married, raise children, and to be flict created by her fear of beginning a new rela- attentive to the males. Arab societies are highly tionship yet also not wanting to be alone. She patriarchal. They remain as such even when disclosed feelings of loyalty to her ex-husband members emigrate to United States. Male domi- that continued even after the divorce had been nance remains strong and the man is identified as finalized. Dating other men felt haram, or the main source of authority [11]. Women in forbidden, similar to having an affair. Her these societies are expected to spend most of husband continued to harass her with phone calls, their time taking care of their families, and it is often calling her a “whore.” Lamia chose to share quite uncommon for them to have careers [60]. custody of her children with him as she felt it was There is a tendency in the West to stereotype important for them to grow up with a father. the Arab woman [24]. The general perception In addition to traditional approaches often uti- remains one of oppressed, abused, and having to lized in cases of domestic abuse, it was important abide by religious and social rules [18]. This for the therapeutic work with Lamia to also focus misperception is especially true of Muslim Arab on understanding the more unique cultural aspects women and is often thought of as a reason behind of her situation. Basic needs such as safety were an inhibition in Arab women’s emotional, social, addressed ensuring the effectiveness of her and sexual development [24]. Such stereotypes restraining order and pairing her with a social may likely be related to the fact that Arab women, worker. Lamia’s strengths were emphasized while having a powerful presence in family throughout treatment, as was her need to gain an decisions, tend to express it privately [3]. understanding of her depression and fear gener- However, more recently, Arab women have been ated from years of trauma. Lamia was empowered challenging these stereotypes, and rather, a trend to test a new outlook on life and enter new rela- toward portraying them differently and more tionships. The mental health provider remained accurately has been observed. The movie sensitive to the importance Lamia placed on fam- Caramel is an example of this trend. It portrays ily, despite the rejection she had endured. Attempts the struggle of Arab women, like Lamia in the were made to include her parents in the treatment. case vignette, toward successful careers and The mental health professional learned about the independence as they age, engage in same-sex role of family and the dynamics of romantic rela- relationships, and deal with “the culture of tionships in Lamia’s culture of origin. Lamia was virginity,” within the confines of their culture encouraged to explore her identity as a Moroccan (http://movies.nytimes.com/2008/02/01/ woman in America and educated about her rights movies/01cara.html?r=0). 9 Mental Health of Arab Americans: Cultural Considerations for Excellence of Care 161

The process of adjustment to American soci- acculturation arise especially in traditional ety presents significant mental health challenges cultures like the Arab one. Despite having a to Arab women [61]. Much of the available litera- common language, immigrants from the same ture on this subject has documented a higher risk area of the world may differ in their patterns of to develop depression compared to males. This is acculturation. This difference depends on the likely caused by the expansion of the particular country and culture of origin [65]. The responsibilities attached to their main role of process, referred to as acculturation stress, can be household management and child rearing leading accompanied by many challenges that are often to excess stress [24]. In a study examining female hard to overcome [14]. The acculturation process Jordanian immigrants, Hattar-Pollara and Meleis is influenced by factors, including country of (1995) found that women experience significant origin, the duration of presence in the United sadness, anxiety, and social alienation in the face States, circumstances leading to emigration, the of the multiple acculturative stressors [20]. These presence of family members remaining behind in stressors included societal bias, financial duress, the home country, access to home country, future management of the household, preserving the intent to live in the United States, proficiency in ethnic identity and the cultural heritage, and English, and accent in spoken English [23] protecting their children from behaviors that they (Fig. 9.1). perceive unacceptable [20]. Exploring the degree of acculturation should In the United States, many Arab women are be an integral part of the mental health assessment seen attempting to cross a bridge socially and of Arab Americans [66]. This plays a special culturally [62]. They search for solutions that feel importance in shaping the attitudes of Arab more acceptable to them in the context of their Americans toward seeking mental health services. lives in the United States. While being careful not Acculturation stress can potentially be expressed to violate their cultural value systems, they seek by a variety of psychological symptoms, such as to break from traditional and patriarchal rules as feelings of marginalization, identity confusion, the blended case demonstrates above. physical complaints, anxiety, depression, and suicidal ideation [67]. Learning a new language as well as new values and laws can exacerbate Acculturation this stress. The same stress is present when they face discrimination and racism [68]. When Arabs Acculturation refers to the adaptation process to emigrate to the United States, they are faced with a new society or culture. In acculturation there is a significant change in their socioeconomic status interplay between immigrant’s attitudes toward [24]. This is possibly related to their inability to the culture of origin and the host culture [63, 64]. afford education, poor compensation at work, Four possible forms of acculturation have been and the difficulty they have in finding employment described: assimilation, integration, separation, in the United States commensurate with their and marginalization. Assimilation is the full educational level [7]. immersion into mainstream majority culture. The assessment of the degree of acculturation Assimilation may not necessarily mean well- also encompasses the degree of identification being. It has potential positive or negative effects with traditional values as compared to the on the mental health of the immigrant [14]. adoption of Western values. Transgenerational Integration suggests a balance between one’s differences between members of the same family heritage and the host culture. Separation is the or between different subgroups of immigrants preservation of one’s cultural ties with no aspects can exist. Some Arab Americans may identify of new host culture, while marginalization means themselves as Caucasian and experience no link no connection to either heritage or host country. to their culture of origin which is more common The mere enumeration of these different forms of if they are born in the United States [22]. Other acculturation can point how problems in Arab Americans would rather seek greater 162 I. Melhem et al.

Religious support Generational Ethnic identity and coping status Discrimination Acculturative stress

Gender

Cultural resources Socio-cultural adversity

- Country of origin - Length of time in US - Reasons for emigration - Family still lives abroad Psychological distress - Ability to return and visit home country - Long term plans in US - Proficiency in English

Depression Anxiety PTSD Other

Fig. 9.1 Acculturation as a dynamic process connection to the Arabic identity [22]. immigrant identifying more with their native Intergenerational conflicts can arise between par- group rather than with the host society [66]. ents and their “Americanized” children, and par- Even after many years spent in the host enting techniques previously used in the country country, the prevalence of psychiatric symp- of origin may no longer be applicable. Corporal toms in the immigrant population continues to punishment, common in certain traditional cul- be elevated despite a documented decline over tures, may be considered physical abuse in the time [66]. Multiple studies involving adult refu- United States. Physical violence or domestic gees found discrimination to predict psycho- issues may face legal consequences that the logical distress and to be associated with recently immigrating Arab may not know. The depression and PTSD [66, 69]. Immigrants fear and guilt associated with losing one’s native with higher perceived discrimination experi- culture and the anxiety related to adjusting to the ence higher psychological distress and lower new culture can lead to significant stress and trust in the new society, which could result in a potential identity confusion. The lack of sense of potential underuse of mental health services as community and absence of the extended family a consequence [3]. network only render this process of acculturation After 9/11, discrimination, bias, and violence more stressful [24]. targeting Muslims and Arabs increased in the United States [3]. Since then, this population has faced increasing scrutiny that resulted in a higher Discrimination incidence of mental health issues. Profiling of traveling passengers became ordre du jour often Discrimination is a significant stressor among not helpful for the safety goals it was trying to resettling immigrants and a major factor nega- achieve [35]. However, only minimal attention tively impacting their health status and mental has been given to this issue by research studies health outcomes [3, 68]. Discrimination, which [3, 70, 71], and the assessment of the impact of involves a cognitive appraisal of threat from oth- these events on this population remains poorly ers, can affect mental health negatively by imped- understood. ing the social adaptation of immigrants [65]. This Perhaps in response to this lack of research, was hypothesized to be caused partly by the there has been a movement among Arab American 9 Mental Health of Arab Americans: Cultural Considerations for Excellence of Care 163 women to fight against discrimination through Muslim given their shared religious background political activism [72, 73]. Many have exercised [1]. Some Muslim patients will involve a religious such activism by wearing the hijab (veil covering figure or authority in their treatment [1]. Similar the head and body) in public spaces where they to other minority communities, clergy are have been criticized or by organizing events frequently asked to perform not only their raising awareness and speaking out against traditional religious and spiritual role but also a abusive behaviors. Arab American women have mental health provider’s one [3]. In Islam, the also worked to actively challenge stereotypes Imam, a male clergy member who leads prayers often held by American compatriots as well as and gives the sermon on Fridays, is sometimes the rigidities within their own cultural and resorted to for counseling services regarding religious backgrounds [62]. In fact, a clinical social and family issues as well as mental study revealed that Arab American men and healthcare [74]. They use the Koran (the Islamic women may respond differently to discrimination, holy book) and the Hadith (holy Scriptures of the where men tend to develop more associated prophet) as tools [74]. In one study, 74% of psychological symptoms [69]. mosques in the United States were found to provide counseling to couples or families [74]. Despite being at the forefront of such services, Religious Considerations Imams may feel that they lack the know-how and resources to address those issues adequately [74]. In mental health, religious and spiritual practices Among Arab Americans, several differences often play a significant role in the treatment exist between Muslims and Christians with process for people with strong faith or who are respect to mental health [14]. Muslims are more highly spiritual. This is no exception for Arab likely to maintain ethnic identification with Arab Americans. religious and family values and a higher Historically, Islam has had a good relationship religiosity than Christians [14]. Christians have with medicine [1]. Many Muslims have strong been found to have less acculturative stress and beliefs about the role God plays in health, illness, an overall better adjustment within American and treatment [1]. The word Islam translates to society. This has been hypothesized to be due to “to submit,” i.e., to submit to the Will of God. maintaining lower ties with their country of Highly religious Muslims may hold the belief that origin and sharing similar religious affiliations humans yield little power over health matters and with most Americans [14]. While both Muslims decisions as God Almighty has ultimate control. and Christians express the same desire for When talking about their illness, they frequently integration into the American society, Muslims use terms like al-hamdu-lillah (“praise to God”) feel more alienated and discriminated especially and insha’Allah (“by God’s willing”) [1]. Prayer after 9/11 [14]. holds a special place in the well-being of the individual. In addition, many regard envy or the evil eye, referred to as hasad in Arabic, as a main eti- Clinical Recommendations ology of disease [1]. To a Muslim, the human for Working With Arab Americans body is considered a gift from God to be treated well [12]. The Islamic scriptures emphasize the The higher rates of anxiety, depression, and importance of a healthy lifestyle, and Muslims are PTSD in Arab immigrants in the United States expected to acquire knowledge and to seek treat- and the effects of immigration on their health ment for their physical and mental problems [1]. status would benefit from further study in order As such, medical advancement and physicians are to validate the existing findings and develop highly valued in Islam [1]. evidence-based culturally sensitive clinical While Islam does not mandate its followers to strategies for assessment and treatment [75]. In seek treatment from a Muslim provider, many the clinical setting, certain cultural characteristics Muslims often prefer that their provider be and culturally sensitive etiquettes could greatly 164 I. Melhem et al. facilitate the provision of mental health care by recommendations that could be used in the daily the providers working with an Arab American. clinical setting but also could help any The table below was created to summarize the professional interested in this population work of many authors who have written on this (Table 9.2). While the clinical experience shows subject [11, 24, 59, 76, 77]. It provides a great advantage for the professional to be of

Table 9.2 Clinical recommendations for working with Arab American patients Clinical issues Arab American characteristics Recommendations Patient-provider Emphasis on trust in rapport building Do not assume resistance if patient doesn’t relationship readily open up Different notions of time Give the patient time especially when discussing personal and emotional aspects Provider seen as an authority figure Do not assume resistance if patient is late to the appointment Importance of social courtesies Be aware of your own limitations in providing care Safety issues: suicidality, violent Study your views of Arab Americans and behavior, neglect their effect on your work with this population Do ask about them but do not consider a negative answer as the definite one if everything else is pointing to the contrary. When in doubt, attend to safety issues urgently by consulting with a provider who is aware of the patient’s cultural differences Termination of treatment Professional appropriate dress Respect formalities (sole of shoes facing the patient is considered an insult) Always shake hands at the beginning and the end (except when opposite provider- patient gender, especially with pious Muslim female) Explain that termination is a growth/ learning process. End with sentences that express “hope” rather than “abrupt stop” Offer the patient to communicate with provider (therapist) when needed in the future if any issue needs to be revisited or if patient is in acute distress Language Different meanings of Arabic terms Be aware of cultural differences in word use Use of euphemisms Avoid the use of jargon Repetition as a means to emphasize ideas Expect patient to repeat or ask the same question for reassurance Use open-ended question Attitude toward mental Unfamiliarity with mental health services Orient to service provided and health confidentiality and explain the role of the provider Fatalistic attitude Assess patient’s expectations of treatment Religious and traditional healers Consult and collaborate with religious and traditional community figures Expectation of minimal participation in Use structured and didactic treatment psychotherapies rather than existential techniques 9 Mental Health of Arab Americans: Cultural Considerations for Excellence of Care 165

Table 9.2 (continued) Clinical issues Arab American characteristics Recommendations Role of family Family as the core social structure Establish alliance with the family of the patient and engage important family figures in the treatment and invite them to sessions when appropriate, family therapy recommended Patriarchal structure Discuss family expectations and their role in patient’s presentation and treatment Family members involved in Do not assume individuation from family decision-making as a goal of treatment or sign of improvement Nonverbal communication between Avoid direct confrontation between family family members members during session Gender Stereotype of Arab women oppressed Do not assume that all Arab women are oppressed within their culture Discomfort with professional of opposite Do not assume that all Arab women are gender the same Gender matching in interpreters and healthcare professionals Display of symptoms Symptoms expressed somatically Avoid pathologizing somatic symptoms Discomfort with discussion of illness Assess cultural background and its relation to current presentation Consider the cultural context when assessing somatic symptoms Address uncomfortable subjects indirectly Acculturation Migratory experiences Understand the immigration experience and its effects on ethnic identity and economical and psychological status Refugees/experienced trauma Explore cumulative, family trauma as well as individual trauma Cultural identity Allow time for trust and to open up about trauma Transgenerational differences Explore ambivalence about ethnic identity Discrimination and stereotyping Be aware that Arab Americans are not considered an ethnic minority in the United States Include categories like “Arab American,” “Arab,” and “Middle Eastern” on forms that require background information Study past and current political events in the United States and the Middle East, the patient’s culture of origin, and their effects on the patient’s current condition and functioning Explore the difference between various generations of Arab Americans Assess the level of potential discrimination experienced by the patient Explore effects of discrimination on self-image, ethnic identity, and social interactions Examine the impact of media messages and stereotypes on your beliefs 166 I. Melhem et al. similar background, one needs be aware of one’s the nuances of words between English and own limitations in cultural sensitivity, specifically Arabic [61]. When discussing negative outcomes given the levels of diversity within the Arab of an illness or a situation, the provider is advised community. to avoid referring directly to the patient and is Most Arab clinicians practicing both within rather to use the third person [53, 61]. Medical and outside the Arab world are aware of the enor- interpreters should be fluent in both languages mous diversity that exists among the Arab popula- and be knowledgeable of the cultural character- tions. This diversity encompasses the many istics of this population [61]. Same gender inter- dimensions of culture including race, religious preters are preferred [61]. In the absence of affiliations, cultural norms and values, language/ medical interpreters, the provider should avoid dialects, social and political contexts, professional the use of family members for interpretation and and educational levels, socioeconomic status, and rather attempt to find within the healthcare pro- acculturation levels. When working with an Arab fession an unrelated individual of the same back- American, clinicians of Arab origins fare better in ground or refer to an Arab-speaking provider their therapeutic plan when they adjust quickly when possible. and flexibly their perceptions and interventions Nonverbal conventions also play a signifi- during the therapy process. Such adjustment cant role in the clinical care of an Arab guides and helps the clinician calibrate how much American. While the Arab patient attaches sig- of the work can be geared toward fostering indi- nificant importance to social courtesies and viduation and/or how much of the work needs to hospitality, the notion of timeliness in the Arab remain within and meet a more traditional cultural culture differs significantly from that in stance. Western culture. The word boukra, translated The fatalistic attitude of some Arab literally, means tomorrow. For the Arab, it may Americans toward health issues and the unfa- mean a “long time or sometime in the future.” miliarity with mental health services can result For example, the patient may be late for in an initial level of resistance to treatment [53]. appointments or may cancel them without noti- The health provider must be attentive to allot a fication. These cultural nuances are important longer time to the initial rapport building with to grasp by the provider in order to contextu- the patient. For certain patients, building trust ally understand their patient’s behaviors and may even supersede the resolution of the prob- not mistake them for disrespect or disinterest lem [61]. Arabs are highly affiliative and cherish in treatment. friendships and close personal connections In addition, the notion of “personal space” is much more than their commitment to tasks and different for the Arab individual compared to the deadlines. The provider should not assume this Westerner. The provider may see his patient stand to be a form of resistance to treatment. The same or sit too close to his family members or close caution should be exercised when terminating a friends [53]. In contrast, the Arab American may therapeutic relationship. Termination should not sit too far from his or her provider especially if of be perceived as rejection or as an irreversible the opposite gender or may avoid direct eye con- process. “See you some time again” may be tact [61]. Arab women, especially Muslim, may more acceptable than “goodbye, good luck or feel uncomfortable being in a room by them- farewell.” selves with a male provider. Also, women who Verbal communication is a vital factor in the observe the hijab are more likely not to shake provision of care to Arab Americans. The Arab hands with the male provider [61]. Rather, plac- patient may use more repetitions, and his or her ing his hand over his chest or heart would be an verbal expressions may be more intense. The appropriate substitute for the male provider [1]. provider is encouraged to use more open-ended Gender matching between the Arabic patient, questions and to be aware of the differences in especially Muslim women, and healthcare 9 Mental Health of Arab Americans: Cultural Considerations for Excellence of Care 167 provider and the interpreter could also be a LGBTQ+ Arab Americans and Their crucial element in how much information is dis- Families closed [1]. In psychotherapy, the Arab American individ- Case Vignette 4 ual tends to be less psychologically minded than the Western individual [50]. The Arab culture A 21-Year-Old Syrian-American Woman predominantly focuses on the “other” and hence With Anxiety may offer less potential for introspection or Aidah is a 21-year-old female born in Syria. She assessment of one’s own needs and experiences emigrated to the United States at age 6 along with [29]. Short-term, didactic, and structured psycho- her parents, an older brother, and two younger therapeutic approaches may be more readily sisters. Aidah’s family is Muslim and resides in a accepted by the Arab American as compared to New Jersey neighborhood with a sizeable Syrian insight-oriented modalities [15]. In other cases, population. Her father works as a physician. Her the cumulative family or collective trauma and mother worked as an English language teacher in the associated high distress level and comorbid Syria before coming to the United States and now psychiatric illnesses may prevent the disclosure primarily attends to household responsibilities. of prior experiences and symptoms. A higher Aidah’s parents are socially conservative and level of trust and sometimes loosening therapeu- strive to maintain the Arab identity of their tic formalities could facilitate such disclosure. In family. While her family arrived in the United these instances, a longer course of therapy would States just 3 years after the 9/11 attacks, Aidah be the better option. experienced little overt racial or religious For Arab Americans, identity is derived from discrimination throughout her childhood. Within the family. The individual’s commitment to the last 2 years, however, growing awareness of family responsibilities is highly praised and lived conflict in the Middle East and increased attention by values. For example, an individual is supposed to immigration policy have given rise to at least to take care of sick family members and the three hate crimes aimed at Aidah’s family, elderly. By the same token, an Arab will turn to including a racial slur written in graffiti on their family members and closest relative when garage door. needing help. Family dynamics generally rest on Aidah was homeschooled throughout most of a patriarchal system where the young respects the grade school. She attended a private high school older. Furthermore, medical decisions are with a diverse population where she first gained frequently taken by the family as a whole rather exposure to more liberal, Westernized culture. than by the patient. Given this strong presence of Aidah now attends a prestigious university the family in the life of the Arab patient, the approximately 3 hours from home and is pursuing clinician may be faced with a potentially a degree in computer science engineering. Her overbearing family. To best manage this cultural parents highly value education for all of their consideration, the health provider is encouraged children and expect Aidah to pursue a doctoral to adopt a family systems perspective that degree in her field. They also expect Aidah to respects family cohesion and takes into soon get married and start a family. consideration the influence of key family Aidah presented to her university’s counseling members in the life of the patient [19]. The center with concerns about increased anxiety, patient’s family goals and expectations should be attention difficulties, and memory problems. evaluated and individuation from his or her During the intake session, she was quick to family avoided [18]. The collaboration with ensure that the content of her sessions could not family members, community leaders [19], be shared with her family or instructors and interpreters, and other caregivers involved in the revealed that her family would likely not approve patient’s care is essential. of her seeking treatment. The therapist, a White 168 I. Melhem et al. female, educated Aidah about the limits of Aidah decided to keep her relationship private confidentiality and reassured her that she could from her family. She processed current and not share information with anyone without her potential losses with the therapist. Aidah was also written permission. Later in session, Aidah linked with LGBT+ student organizations as well expressed feeling conflicted about her identity as as LGBT-affirming Arab American groups on an Arab woman in the United States. She campus. (end of case vignette 4). described herself as having “two faces,” one that For nearly as long as mental health has been she shows with her family and a second that she considered a distinct field of practice, the reigning shows with her peers. Aidah shared that she view of homosexuality was pathological in drinks alcohol and occasionally smokes nature. A momentous indication of change in this marijuana with her friends. She noted that she view occurred in 1973 when the American does not wear hijab regularly and is beginning to Psychiatric Association (APA) removed question her faith in God. Aidah acknowledged homosexuality from the Diagnostic and feelings of guilt as well as continuous worry Statistical Manual of Mental Disorders (DSM) as about what might happen if her parents were to a categorical disorder [78]. The idea that learn about her behavior. Throughout the intake homosexuality occurred solely as a sign of session, Aidah’s therapist was careful to assess “weakness” or severe psychological Aidah’s acculturation level, immigration story, maladjustment was largely discredited by and level of identification with her Arab culture, advances in scientific research. Alongside the in addition to typical psychiatric variables. movement toward more ethical responses to Early sessions with Aidah focused on rapport variances in sexual orientation has been the building and skill building interventions, such as movement toward a more culturally sensitive relaxation and organizational techniques. provision of mental healthcare [79]. The rapid Eventually, Aidah disclosed that she had been in diversification of the United States has led to the a romantic relationship with a woman for creation and refinement of multicultural approximately 8 months. She shared that her initiatives as well as an influx of research efforts partner, a 24-year-old American woman of Indian designed to shed light on the provision of descent, is dissatisfied with her refusal to tell her culturally sensitive mental healthcare [80]. family about their relationship. The therapist In this way, it is crucial for mental health pro- attended to the possible consequences of viders to understand that beliefs regarding homo- revealing her relationship to her parents; Aidah sexuality among Arab Americans may be as confirmed that she would likely be viewed as diverse as they are in the general American morally or mentally ill and potentially ostracized population. Level of education and acculturation from her family. She stated that her parents not may play a role in shaping one’s view of only disapprove of same-sex relationships but homosexuality. Arab American individuals with a that they would also reject her relationship based high degree of acculturation – or, in other words, on the ethnic and religious identity of her partner. those that have adopted more Westernized values Aidah also acknowledged doubting the in lieu of traditional values – may be less likely to “authenticity” of her sexual identity at times and hold a pathologized view, for example. However, expressed wonder if peers in high school and now the overarching cultural message is that college had too easily influenced her. homosexuality is objectionable [81, 82], likely To help Aidah address these concerns, the influenced by a myriad of complex factors, therapist provided emotional support with no including the political, religious, economical, judgment about whether Aidah should embrace patriarchal, and even internationally influenced her sexual identity. Instead, Aidah’s symptoms facets of Arab society. and concerns were normalized, and both the Even in countries deemed relatively liberal in affirming and rejecting aspects of her Arab the Arab world, a discussion of LGBT rights has culture were acknowledged. For the time being, not openly permeated political agendas [83]. 9 Mental Health of Arab Americans: Cultural Considerations for Excellence of Care 169

Same-sex sexual activity is often illegal, as is that may lead to harm in treatment and research. same-sex marriage and adoption. Same-sex Individuals served deserve protection from harm relationships in most Arab countries are by culturally insensitive care or abrupt, considered illegitimate in legal terms, and openly discriminatory referrals. Clinicians must be gay individuals are often prohibited from serving careful to choose interventions that do not pose a in the military [84]. By comparison, same-sex disproportional risk of harm (such as some relationships may be grounds for time in prison, conversion therapies, which seek to change a torture, castration, deportation, or death in more person’s sexual orientation) or encourage conservative Middle Eastern countries [84]. In confrontation with family or cultural values that these more conservative regions, anthropological could intensify problems with rejection or research has detected a sense of insecurity that isolation. The APA discusses the need for traditional morals will be diminished as the affirmative responses that contest the liberal practices of “the West” become more criminalization, discrimination, and prejudice universally widespread. It has been suggested against homosexuality promoted by sexual that these groups may perceive their own ideals stigma inherent in society [87], yet Arab of sexual expression as more acceptable, in terms Americans are often vulnerable in that they can of morality and general safety, to the less face backlash from their communities if they conservative practices of European and American become more open or accepting of homosexuality. cultures [83]. These subtle conflicts between professional As a result, therapeutic interventions aimed at standards and culturally sensitive practice can promoting acceptance of all sexual and gender become more apparent when making treatment identities by Arab American individuals or their decisions. For example, in cases where a referral families, even if applied skillfully, invite risk of is contemplated, a mental health provider may particularly damaging familial and societal consider their own competence and experience in rejection and may actually promote further working with Arab American clients. At the same psychological conflict for all involved. There are time, the provider must gauge the potential harm a number of factors a mental health provider a referral might bring to a patient and their family. must consider – the Arab culture of the patient Arab Americans underutilize mental health and their family, attention to intergenerational services as compared to other groups [11], and an discord potentially created by an individual’s indiscriminate decision to refer seriously upbringing within American society, the stance undermines the amount of strength it may have of one’s professional organization (e.g., APA, taken to overcome reluctance to seek help in an ACA, NASW) on homosexuality as a non- unfamiliar culture. pathological, normal variance in sexuality, the In order to remain compliant with professional limited evidence that exists for the efficacy of standards of practice, mental health providers conversion therapy and its potential for harm, and should adopt a non-pathological view of finally, the danger of placing an Arab American homosexuality [87]. This means that they may be individual at odds with their family and culture. in direct disagreement with the Arab American Keeping in mind the level of familial emphasis family or individual to whom they provide within Arab culture, this last variable is especially treatment. Although few empirical studies have critical. been done to address the specific mental health Most professional organizations within the needs of Arab Americans, a set of clinical mental health field, including the American recommendations (see Table 9.2) have been Psychiatric Association [85] and the American developed to assist mental health professionals Psychological Association [86], expect their working with this population. Level of members to abide by a written code of ethical acculturation may serve as an important backdrop principles and standards that encourage to conceptualizing the psychological concerns of awareness and management of potential factors an Arab American individual or family and shed 170 I. Melhem et al. light on the view of sexual identity or gender and support. The removal of preconditions placed expression, as well as its etiologies. Mental on the outcome of treatment is especially crucial health professionals are urged to consider past when working with Arab Americans and their and current political events occurring both in the families – a “push” for a particular outcome, United States and the Middle East and to especially one that may contradict the family’s acknowledge the impact of media messages and feelings about sexuality, has the potential to stereotypes as well as possible discrimination create significant personal and family conflict. individuals may have faced based on their Arab Although a clinician may understand that a identity alone. Exploration of immigration reversal of sexual orientation is unlikely to occur, experiences and its multilayered effects is crucial they must remain empathetic to the individual’s as there is potential for complex trauma, such as desire to change or reject an identity. in the case of families who have left their This framework also stresses the importance countries due to war and political unrest. The of thorough and comprehensive assessment dynamics of acculturation highlights a vital need strategies. It must be understood that an to understand that an Arab American’s concerns individual’s distress is complex and is not always related to sexual or gender identity are not likely directly tied to their concerns about their sexual to occur within a perfectly sealed vacuum. Rather, identity, mirroring recommendations for general they are heavily influenced and perhaps com- treatment that mental health professionals must pounded by a multitude of variables. take care to gain a full understanding of an Arab Again, the role of family is central in Arab American individual, including their particular cultures, and an individual may seek to preserve country of origin, culture, religion, level of their family identity before attending to their own acculturation, experiences with discrimination, needs. The families of Arab Americans may and immigration and trauma history. expect direct involvement in decision-making Assisting a client with active coping is a third related to treatment goals and outcomes. As a element of this framework [87]. Cognitive result, it is important to establish a strong alliance strategies, such as tapping into cognitive with family members and hold family-oriented distortions (i.e., all or nothing thinking, either-or sessions, which should involve exploration of dichotomies) and refocusing on the more family expectations and psychoeducation accepting elements of one’s religion and culture, regarding their role in the patient’s psychological are thought to be helpful in addressing a client’s presentation and treatment. Therapeutic difficulty living within a society or cultural group interventions that utilize direct confrontation that may not affirm their sexual identity. These should be avoided or used with caution, and a strategies can be paired with a detection of more indirect approach to sensitive areas of negative self-appraisals and exploration of discussion is preferred. This knowledge is internalized stigma. This affirmative framework imperative where Arab American families request also encourages mental health providers to treatment for a family member’s sexuality and consider emotion-focused strategies to improve a openly object to their gender or sexual identity; patient’s ability to cope with loss and grief, this is a case in which a clinician might normally especially for those individuals who have lost or respond by promoting direct exploration of such had to give up membership in a particular group a conflict. (i.e., their religious group). Such strategies In 2009, the American Psychological should also address uncomfortable feelings of Association [87] proposed a framework of dissonance, ambiguity, and uncertainty Affirmative Therapeutic Interventions forsurrounding sexual experiences and identities. individuals who may seek treatment to change or These coping strategies are highly relevant for “fix” their sexual orientation or gender expression. Arab Americans with families or communities The first element of this framework is to take a who hold a negative view of homosexuality. client-centered approach based on acceptance Research has found mutual support groups to be 9 Mental Health of Arab Americans: Cultural Considerations for Excellence of Care 171 helpful for individuals struggling with their and treatments. This level of diversity creates sexual identities [88]. As a result, providers challenges even to the Arab clinician treating an should emphasize social support and include Arab patient. Cultural sensitivity cannot be both “ex-gay” and LGBT-affirming groups as assumed in the culturally similar patient-provider well as individuals trusted by the patient who dyad. The paucity of evidence-based knowledge have been consistently supportive. It is recognized of Arab American mental health correlates that gaining social support can be especially impedes the professional’s ability to provide cul- difficult for individual’s whose communities turally sensitive treatments. “reject” their sexual orientation; in such cases, a This population continues to diversify and provider may reframe this problem as an external evolve even further with the generations of rather than internal issue [86]. Because of the offspring of Arab American couples and the special emphasis on the importance of family current and future waves of immigration from the within Arab American cultures, the efficacy of Arab world. In order to understand the evolving this element can be unclear. clinical and cultural characteristics and to meet Finally, mental health providers are encour- the medical and mental health needs of this aged to engage in identity exploration with their population, significant resources are necessary. patients and to maintain an understanding of iden- The researchers, educators, and professionals tity development [87]. Mental health providers working with this community need culturally should possess knowledge of models of sexual sensitive guidelines and data to support their minority identity development as they participate endeavor. This is especially crucial in mental in the active process of “exploring and assessing health where missing cultural considerations and one’s identity and establishing a commitment to nuances can lead to misdiagnosis and suboptimal an integrated identity” [86]. This approach holds treatments. Training professionals in culturally no assumptions, however, about a desired out- sensitivity avoids the unintentional violation of come and recognizes that outcomes may vary and traditions and beliefs and counters stereotype and change with time. For example, an individual may misconception [61]. The training of bilingual either adopt or reject their sexual identity or professionals and medical interpreters who choose not to specify a sexual identity at all. In understand not only Arab Americans but also the addition, this approach seeks to expand previ- dual cultural heritage of their American-born ously rigid or inflexible definitions of various children will be critical in building culturally identities. A provider must explore the multiple sensitive health services. This is especially identities that exist within a single person. A gay important in women’s issues and women’s rights Arab American, for instance, may be having dif- whether it is about acculturation, gender roles, ficulty integrating their American and Arab cul- and new family laws or in the prevention of tural identities, on top of a struggle between their domestic violence. As Arab American women religious and sexual identities. Arab Americans adjust to living in the United States, they face the are also more likely to hold identities strongly tied challenge of preserving their Arab cultural values to their collective social groups with less empha- while heading toward liberation. The liberation sis on an individualistic perspective of the self. of women is not simultaneous with the abandonment of important and valuable customs. Further research should be conducted to study Conclusion the cultural variations between the diverse groups of Arab Americans and their mental health with a Arab Americans represent a highly diverse com- special emphasis on family and gender issues. It munity that remains poorly understood despite should study the differences between the various the significant media and public attention it has ethnic and cultural groups among the diverse received in the recent years. The diversity of Arab Arab American populations and gain a better societies is often missed in clinical assessments knowledge of their attitudes toward mental health 172 I. Melhem et al.

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Shirin N. Ali

Introduction understanding the patient’s unique subjective experience. After reading this chapter, the reader This chapter will describe an approach to mental will hopefully gain more knowledge about Asian health assessment and treatment in Asian American health beliefs and culture and integrate Americans, a diverse and rapidly growing group this into his or her approach to mental health within the US population. The chapter places an practice, education, and research to effectively emphasis on understanding concepts related to help Asian American patients. This chapter con- how Asian Americans may understand mental cludes with three blended cases based upon my health conditions and how mental health profes- work and cases of colleagues shared with me sionals can approach this population in a cultur- from years of experience in working with Asian ally sensitive and curious manner. I hope this Americans. These cases will help the reader to chapter will help mental health clinicians, educa- synthesize the different topics and themes dis- tors, and researchers develop a thoughtful and cussed in the chapter in realistic clinical scenar- flexible approach to evaluating and working with ios. These cases will clearly demonstrate the Asian American patients. To develop a complete complexity and diversity of Asian American understanding of the patient, the mental health patients and help to model an integrated approach professional will have to weave together the to working with Asian Americans in a culturally patient’s unique health beliefs, culture, language, sensitive manner in clinical, research, and educa- family, religion, narrative, genetics, pharmaco- tional settings. logical history, and relevant life experience. Asian Americans cannot be treated as a mono- lithic group, and in the following pages, topics Who Are Asian Americans? and themes will be raised that lead the professional away from viewing the patient’s difficul- Based on US Census information from 2016, ties through only one lens and toward there were an estimated 21.4 million persons of Asian descent living in the United States [1]. Asian Americans were the fastest growing racial S. N. Ali (*) group with the largest proportional population Department of Psychiatry, Columbia University, increase between the 2000 and 2015 census [2]. College of Physicians and Surgeons, New York, NY, USA California and New York have the largest popula- e-mail: [email protected] tions of Asian Americans at 6.5 and 1.8 million

© Springer Nature Switzerland AG 2019 175 R. Parekh, N.-H. T. Trinh (eds.), The Massachusetts General Hospital Textbook on Diversity and Cultural Sensitivity in Mental Health, Current Clinical Psychiatry, https://doi.org/10.1007/978-3-030-20174-6_10 176 S. N. Ali people, respectively [3]. It is an extremely het- A Brief Immigration History erogeneous group with tremendous diversity. Currently among people who identify with one The first Asian immigrants to the United States country of origin, the largest subgroup among arrived from Japan in 1843 and were soon fol- Asian Americans are of Chinese descent, followed by Chinese men who came in the 1850s lowed by Indian Americans, Filipino Americans, and 1860s to work on the transcontinental rail- Vietnamese Americans, Korean Americans, and road, on gold mines, and in agriculture [1, 4]. The then by Japanese Americans [2]. Not surpris- Chinese Exclusion Act of 1882, which put an end ingly, after English and Spanish, Chinese is the to all new immigration from China, was a reflec- third most widely spoken language in homes in tion of the opposition to Asians immigrating to the United States. While Asian Americans have the United States and becoming permanent resi- made tremendous strides in acculturation since dents. The Asian exclusion Act of 1924 was a the first Chinese and Japanese immigrants came continued response to concerns about Asian to the United States in the mid-1800s, Asian immigration, which limited the new immigrants Americans are still largely a population made up per year from East Asia, Southeast Asia, and of immigrants, with 73% of Asian American South Asia [2]. Asian immigrants were thought to adults having been born in another country [2]. be unable to assimilate into the United States Among Asian Americans, 26% live in a multi- population due to phenotypic differences in generational family, defined by having at least appearance, unlike European immigrants. A two adult generations in the same household, Supreme Court case in 1923 of the United States which is higher than Whites, Blacks, and Hispanic vs. Bhagat Singh Thind denied an Indian immi- Americans [2]. On the whole, Asian Americans grant the ability to apply for citizenship citing have a relatively high educational status, as 51% this concern in the official decision [4]. The doubt of Asian American adults over age 25 are college about the allegiance of those of Asian origin to graduates, compared to 30% of the general popu- the United States lasted well into the middle of lation. However, there is disparity of percentage the twentieth century. During World War II, over of college graduates among different ethnic 80,000 US-born citizens of Japanese origin were groups among Asian Americans. For example, held in internment camps by the government [4]. only 18% of Cambodian Americans over age 25 Immigration from Asia radically changed over are college graduates, which is lower than the the course of the twentieth century with different general population. Approximately half of ethnic subgroups greatly increasing as a response Korean, Chinese, Japanese, and Filipino to the loosening of governmental restrictions and Americans over age 25 are college graduates. quotas. For example, in the middle of the century, Indian Americans have a much higher percentage naturalization and immigration of the war brides of college graduates over age 25, 72%. These of US soldiers from Japan, Korea, and Vietnam interethnic differences may reflect different became permissible [4–6]. In 1965, the immigration patterns from the countries of ori- Immigration and Nationality Act ended quotas gin. While the median income of an Asian with regard to Asian immigration and lead to American household is $73,060, and higher than huge increases in the numbers of immigrants the national median, 8.5% of Asian Americans from Asia. This act also changed the ethnic land- lived in poverty in 2009 [1]. Additionally, Asian scape of Asian immigrants, who until that time American households are often larger than those had largely been from Japan, China, and the of other ethnic groups. Asians make up approxi- Philippines. In the 1970s, there was an influx of mately 11% of undocumented immigrants to the refugees from war-torn Laos and Cambodia [7]. United States [2]. While these facts and figures Currently, Asians among immigrants are most do not reflect the diversity of the Asian American likely to come to the United States with work population, they help to provide a broad over- visas but also come through student visas, tempo- view of the makeup of this group. rary visas, and unauthorized status [2]. 10 An Approach to Mental Health in Asian Americans 177

Today, as a result of the varied historical have lower rates of psychiatric disorders com- waves of immigration, there is tremendous diver- pared to other populations. Due to potential cul- sity among the immigration and acculturation tural bias in the reporting of and asking about experiences in Asian Americans. The term Asian symptoms, it was unclear whether or not accurate American captures the breadth of experience of data about mental health conditions in Asian an elderly Japanese American man whose family American was captured by numerous studies. has been in the United States for many genera- Culturally informed ways of expressing symp- tions and the 18-year-old female refugee from toms, prevalence of somatization, and culture- Myanmar who recently arrived to the United bound syndromes were all raised as possible States. Despite their age gap, the Japanese confounding factors. The report clearly states American man whose grandparents immigrated that there were inadequate data about the preva- in one of the early waves immigration will likely lence of disorders in Asian Americans who did be more acculturated than the 18-year-old who not report mental health concerns and did not see arrives to resettle in a very foreign culture. As the mental health professionals. Rather than demon- chapter’s focus turns toward mental health in strating that Asian Americans were a resilient Asian Americans, it will be important to continue “model minority” group, the report showed that to consider each patient or family’s immigration the scope of mental health problems of Asian history as it informs aspects of who they are and Americans was not adequately detected. Without what issues may arise when they may present perceiving a realistic mental health need, treat- themselves to mental health professionals. ment could not occur, except for high acuity populations, like Southeast Asian refugees with post-traumatic stress disorder, whose need was Prevalence of Mental Health more evident [8]. A 2016 study by Cook and Disorders in Asian Americans coauthors evaluated disparities in access to men- and Utilization of Mental Health tal health care among different ethnic groups. Services Unfortunately, their study revealed that there has not been significant improvement in access to According to the groundbreaking Surgeon mental health care for Asian Americans from General’s Report on Mental Health in 2001, there 2004 to 2012; persistently low access of rates to was little adequate data about the prevalence of care continues despite the grave concern about mental health disorders in Asian Americans. One this issue expressed in the Surgeon General’s of the larger studies mentioned in this report, the Report in 2001 [9]. CAPES study, demonstrated that Chinese Large-scale studies have yielded useful data Americans in the Los Angeles area had a moder- about the prevalence of mental health diagnoses ate rate of depression, with 7% of study partici- in Asian Americans and utilization of mental pants endorsing having experienced depression health services. However, diagnosis-specific in their lifetime and 3% in the prior year [8]. studies have focused only on ethnic subgroups of Studies in the 1980s and early 1990s that assessed Asian Americans, and there are no reliable data symptoms of depression rather than the diagnosis on the prevalence of psychiatric diagnoses in of depression in Asian American populations Asian Americans as a whole. One of the large- found higher rates of depressive symptoms in scale studies is the National Latino and Asian Japanese Americans, Korean Americans, Filipino American Study (NLAAS) that reflects the prev- Americans, and Chinese Americans in various alence of psychiatric diagnoses to be 0.8%. This major cities in the United States [8]. One of the study was designed to assess the 12-month preva- concerns underscored in the Surgeon General’s lence of mental health disorders from 2002 to Report is the lack of adequate data about DSM 2003 among Asian Americans and Latinos, to diagnoses in Asian Americans, and the report assess the psychosocial context of the emergence questioned whether or not Asian Americans truly of the disorders, and to determine how often 178 S. N. Ali mental health services were sought, in compari- Table 10.1 Findings from large-scale studies of mental son with White, Hispanic, and Black populations health in Asian Americans [10]. In one analysis by Dr. Jennifer Abe-Kim of Study Mission Major findings the NLAAS data, 8.6% of the population sur- National Assess the 0.8% prevalence veyed sought mental health treatment compared Latino and prevalence of of mental h Asian mental health health diagnosis to 17.9% of the general population when assessed American diagnoses in 8.6% of Asian in other large-scale studies [11]. In the general Study Latinos and Asian Americans population, 41.1% of persons with a probable (NLAAS) Americans from sought treatment DSM IV diagnosis sought psychiatric treatment 2002 to 2003 compared to 17.9% of general compared to 34.1% of Asian Americans. population Additionally, the propensity to use mental health More recent services was inversely correlated to generation of immigrants less immigration. Second-generation immigrants likely to use mental health were more likely to use mental health services services than immigrants; third-generation immigrants 8.8% lifetime were more likely to use mental health services prevalence of than second-generation immigrants at a rate more suicidal ideation 2010 Assess tobacco, Rate of illicit similar to the general population [11]. National drug, and alcohol drug use 3.5% In the NLAAS study, the prevalence of life- Drug Use use in adolescents per month, lower time suicidal ideation in Asian American popula- Survey on and adults than other ethnic tions was found to be 8.8%, and the prevalence of Health groups Among alcohol suicide attempts was found to be 2.5%. Factors users, 8.8% that were positively correlated with suicidal ide- reported binge ation and attempts include being female, conflict drinking in the with family, a history of depression or anxiety, last month Rates of and perception of discrimination. Stronger iden- substance abuse tification and sense of belonging with one’s eth- or dependence, nic group were negatively correlated with suicidal 4.1%, lower than ideation and attempts [12]. The 2010 National other ethnic groups Drug Use Survey on Health by SAMHSA, a large-scale survey on mental health and alcohol, Sources: References [10–13] tobacco, and drug use patterns among over 60,000 responders over 12 years old, showed that For example, Yeung et al. in 2004 found the prev- the rate of illicit drug use was 3.5% in the month alence of major depressive disorder among prior, lower than Whites, Native Americans, Chinese Americans in a primary care setting in Blacks, or Hispanics. Among the 38.4% of Asian Boston to be 19.6%, much higher than the esti- Americans who endorsed alcohol use in the mate from the CAPES study in Los Angeles month prior, 8.8% were binge drinkers and 2.4% described earlier [14]. Another study from 2000 were heavy drinkers of alcohol [13]. Rates of found that the prevalence of panic disorder in substance abuse or dependence were lower Cambodian refugees being treated at a psychiat- among Asian Americans at 4.1% compared to ric clinic was approximately 60% [15]. Another other ethnic groups, which is consistent with study examined the prevalence of eating disor- what other studies have found [13] (Table 10.1). ders in Asian Americans based on data from Smaller-scale studies in specific ethnic popu- NLAAS study and found overall low prevalence lations of Asian Americans have identified preva- of eating disorders in Asian Americans, less than lence rates in these subgroups, but conclusions 1% for anorexia and bulimia. Women had a from these studies do not necessarily generalize higher lifetime prevalence of binge eating disor- to the heterogeneous group of Asian Americans. der than men, 2.67% compared to 1.35% [16]. 10 An Approach to Mental Health in Asian Americans 179

The author believes that it is difficult to draw Idioms of Distress Among Asian conclusions about a particular individual based Americans on these heterogeneous data. One interpretation of these data is that mental health professionals It has been well established that certain ethnic should expect that refugees from Asia will likely groups, like Asian Americans, are more likely to exhibit symptoms of anxiety disorders. However, express social or emotional distress through with less high-acuity populations, the mental bodily symptoms and medical help-seeking, par- health professional should be more vigilant for ticularly in cultures where the expression of emo- mental health symptoms, which may be underre- tional distress may be discouraged [20]. ported or may manifest in different ways, as will Somatization has referred to physical symptoms be reviewed later on in this chapter. in psychiatric disorders as well as physical symp- The Surgeon General’s Report in 2001, in toms without an organic cause. Historically, addition to emphasizing the need for better epi- researchers have also noted a higher prevalence demiological data on mental health conditions, of somatization in populations who are making also highlighted the low utilization of mental either cultural or geographic transitions, particu- health services by Asian Americans compared larly refugee populations [20]. Asian Americans to other minority groups, which has continued are likely to somatize as a result of tacit cultural to be true in the ensuing decade when compared prohibitions against verbalizing psychological to Whites, Blacks, and Hispanics [8, 17]. Since distress. Somatization also may result in more that time, many studies have examined this help for the patient from religious figures, family, question with differing results. Barriers for the and traditional healers than expressing distress in individual Asian American patient may include psychological terms [21]. In a Japanese psycho- any of the following: cultural bias in how the somatic clinic, Nakao et al. found amplification patient describes his symptoms, bias in how the of somatosensory symptoms occurred in patients clinician or researcher assesses the symptoms, who had difficulty identifying and expressing decreased perception of need for treatment, their feelings [21]. Another study found that stigma, foreign-born status, wishing to save among Chinese Americans, individuals who face, initial use of family support and tradi- somatized were most likely to seek professional tional healing methods, focus on somatic symp- help and that individuals with anxiety or depres- toms, length of time in the United States, lack sion were less likely to seek help than those with of culturally appropriate services, lack of lan- somatoform disorders [22]. An earlier study of guage appropriate services, and lack of health somatizers among Chinese American and White insurance [8, 11, 17–19]. For every 100,000 patients in Boston who did not express psycho- Asian American and Pacific Islanders, there are logical distress found that Chinese Americans 70 Asian American and Pacific Islander mental were more likely than Whites to be “true somatiz- health-care providers, which is less than half of ers” and in both populations, somatization was the number of providers for Whites. Also, Asian associated with the presence of a mood disorder Americans may have difficulty accessing the or an anxiety disorder [23]. US health-care system in general, as suggested More recent studies have questioned the by the fact that Asian Americans who are assumption about the relationship of somatization Medicaid eligible are much less likely to have and perceived need of mental health treatment in Medicaid than their White counterparts [18]. Asian Americans. Based on data analyzed from While it is not possible to review all of the the NLAAS study, physical symptoms in Asian nuances of the methodological difficulties in Americans were associated with a greater sense of assessing the prevalence of mental health disor- need for mental health treatment [24]. In another ders in Asian Americans and the disparity in study by the same authors, also based on data their treatment, excellent reviews are provided from NLAAS study, Asians were actually less elsewhere [17, 18]. likely to report three or more physical symptoms 180 S. N. Ali than Whites and Latinos [25]. Somewhat surpris- Table 10.2 Common cultural syndromes of distress in ingly, more acculturated individuals were likely to Asian American populations report more physical symptoms than less accul- Asian country turated people, even with adjustments for psycho- Name where seen Features logical distress, medical conditions, and disability, Amok Southeast Asia Violent and aggressive which may reflect in part the better health of episodic behavior recent immigrants. Taken together, these findings without clear suggest that somatization, while an expression of cause, mostly in distress, can lead to greater perceived need for males Dhat South Asia Anxiety about mental health services in Asian Americans. discolored or lost However, somatization alone cannot account for semen the lower utilization of mental health services by Hwa-byung Korea Related to Asian Americans [24, 25]. It is also very impor- suppression of tant to be aware of the possibility of somatization anger; insomnia, fatigue, panic, in the primary care setting. While some Asian pain, GI distress, Americans with somatization may seek mental fear of death health care, others may seek help in the primary Koro Southeast Asia, Sudden fear of care or medical specialty setting. Practitioners in South Asia, genital retraction these areas should consider the possibility of China into the body and death from anxiety somatization as well as mental health diagnoses or paranoia when evaluating a patient’ physical symptoms. Latah Southeast Asia, Extreme The meaning and social use of somatization may particularly sensitivity to fright also have shifted over time as the population of Malaysia, with dissociative Thailand, Japan, or trance-like Asian Americans has continued to diversify in and the behavior ethnic origin and acculturative status. Philippines Qi-gong- China Episodic psychotic induced or dissociative psychosis reaction after Cultural Concepts and Idioms improper practice of Distress of Qi-gong Neurasthenia China Physical and Cultural syndromes of distress are repeated clus- mental fatigue and ters of symptoms and behaviors more prevalent dizziness, headaches, sleep to a geographic region, community, or group problems, which can cause both physical and mental dis- problems with tress in an individual and may result in impair- memory, GI ment of functioning and help-seeking behavior distress (DSM5). The symptoms may include somatic Taijin Japan, Korea Intense fear that kyofusho one’s physical symptoms as well as symptoms that may or may features, smell, or not overlap with a psychiatric disorder classified behavior is in the DSM [26]. Specific cultural concepts of displeasing or distress have been associated with particular offensive to others Asian and Asian American populations and are a Sources: References [26–33] continued area of study. Psychiatric researchers and clinicians alike continue to determine how inquiry, and the idea of a cultural syndrome has best to approach their diagnosis and treatment continued to be refined and reconceptualized. For (Table 10.2). example, a review on amok challenged the notion Identification and management of cultural of this being only a culture-bound syndrome syndromes is a continued controversial area of given the more frequent episodes of violence and 10 An Approach to Mental Health in Asian Americans 181 aggressive behavior in Western countries as well cians and researchers are continuing to work to as Asian countries, by people of Asian descent better refine the criteria of cultural syndromes. and non-Asian descent [27]. The author of the For example, the definition of taijin kyofusho in review recommended screening for amok in all DSM5 compares and contrasts the disorder with patients in order to have amok as part of a differ- the definition of social anxiety disorder, body ential diagnosis and expanding the assessment of dysmorphic disorder, and delusional disorder in a patient’s risk for violence. The author of the DSM5. The DSM5 also notes that that clusters of review suggested treating people at risk for amok similar symptoms of the disorder have been pres- as psychiatrists would any patient at risk for vio- ent in other contexts, such as the United States, lence, assessing for mood, psychosis, substance Australia, and New Zealand [26]. Efforts are also abuse, and personality disorders and recommend- being made to recognize new cultural syndromes, ing treatment to minimize harm for the individual such as hikikomori, a syndrome of social with- and society in a person at risk [27]. Choy et al. drawal in Japanese adolescents and young adults examined two features of the offensive subtype who may avoid school or work for years and do of taijin kyofusho in patients diagnosed with not meet criteria for another psychiatric disorder social anxiety disorder in the United States and [34]. Cultural syndromes and idioms of distress Korea and found an association between the will continue to be a challenging area for clini- culture-specific symptoms and severity of social cians treating Asian Americans as there is a anxiety, suggesting more overlap in DSM diag- strong need for additional research and consen- noses and taijin kyofusho than previously sus on how these disorders are conceptualized thought. This conclusion raises the possibility of and managed, which has continued to evolve incorporation of other symptoms thought to be with DSM5. cultural into DSM criteria for psychiatric disorders, which has occurred with DSM5 [26]. The expansion of the notion cultural syndromes has Religion, Philosophy, and Health also been raised by other studies that show that Beliefs dhat or semen loss anxiety occurs also in China and Western Europe and that latah may occur in Many values and beliefs common among Asian White and Black populations [28, 31]. The preva- American populations have underpinnings in lence of culture-bound syndromes may also con- Asian religions and philosophy. These value sys- tinue to shift. In their study, reviewing the history tems are comprehensive, describing the integra- and prevalence of neurasthenia in China, Lee and tion of the body and the mind as well and an Kleinman postulate that the worldwide impact of approach to managing both one’s internal and the DSM has made it less likely that Chinese psy- external world. Asian Americans are an extremely chiatrists use the diagnosis of neurasthenia in diverse group, and while all Asian Americans China [31]. Cultural syndromes and idioms of will not uphold these beliefs, it is useful to briefly distress continue to evolve over time, particularly review them here as they inform the conceptual- as technology and communication continue to ization of mental health and illness as well as impact the global exchange of information and general cultural values in many Asian cultures. ways of understanding illness. Much of Eastern philosophy is based on prin- There are methodological barriers to further ciples in Confucianism, Taoism, Hinduism, and characterizing cultural syndromes. One study Buddhism. Confucian thought brought order to described the development of a validated scale to Chinese civilization by emphasizing concepts assess symptoms of Hwa Byung in Korean col- such as interpersonal harmony, acceptance of a lege students but raised the question of whether person’s place in society, hierarchy within the or not the scale would necessarily be valid in family with older adults and males in higher posi- Korean Americans [29]. Additionally, as with tions, unconditional obligation toward the family, depression and other disorders in the DSM, clini- and orientation toward the group rather than the 182 S. N. Ali individual [35, 36]. Taoism emphasizes the excessive worry about semen and reassured him importance of maintaining balance and harmony that semen loss was not dangerous [42]. A patient both internally and with the larger world, respect- may also ascribe to a more pluralistic health belief ing nature, and maintaining personal qualities of system and pursue allopathic and traditional treat- humility and receptivity [36, 37]. ments simultaneously. For example, a Chinese In Buddhism, the individual cultivates com- American patient may believe that his low energy passion for the suffering in others, acceptance of and mood are the result of an imbalance of yin and one’s fate or karma as a result of acts in a past yang and may wish to take traditional herbs from a life, and an acceptance of the ephemeral nature of root doctor along with the antidepressant recom- life, as well as emphasis on nonattachment to mended by his psychiatrist [42]. Understanding aspects of the self [38, 39]. Elements of animism, traditional beliefs may also help mental health cli- belief in the existence of spirits, gods, and ghosts nicians, researchers, and educators gain insight and the belief in a larger spirit world infused in into a family’s approach to managing a particular natural inanimate and animate objects, has condition in a family member and the challenges informed elements of Asian philosophy from that may arise. When a social worker recommends Taoism, Confucianism, and Buddhism that that an elderly Vietnamese woman with dementia include respect or worship for ancestors as a vir- go to a nursing home to alleviate stress in the fam- tue [39]. Hinduism and Islam are the most com- ily, her primary caregiver daughter may acknowl- mon religions in South Asian nations. Aspects of edge the difficulties of care giving but believe that Hindu belief have overlap with Buddhism such as it is her duty to care for her mother, that it may give the values of knowledge of life, emotional regu- her good karma, and that it is necessary for her to lation, control over desire, the value of humility, demonstrate compassion to those who are suffer- and the importance of societal duty [40]. Muslims ing. The breadth of religions and philosophies also have a strong belief in destiny or fate, similar upheld by Asian Americans was briefly reviewed to karma, in that events occur because of the will here, but the mental health clinician can improve of God, and similar ideas of sin to Judeo Christian their understanding of the individual Asian religions. Many Muslims also believe in the spirit American patient’s approach to his mental health world of the jinn and some may have supernatu- by learning more about his or her particular belief ral beliefs about the evil eye [41]. systems. These different religions and philosophies are very tied to beliefs about health and the mind and body in Asian cultures, and patients use their Asian American Family Culture beliefs as a way to understand their difficulties. What Western-trained psychiatrists may consider Based on the deeply ingrained idea of filial piety in a psychiatric problem, an Asian American indi- the vast majority of Asian cultures, the family is vidual may conceptualize as a psychiatric prob- the unit on which society is based. Filial piety is a lem, culture-bound syndrome, physical problem, core value based on Confucian principles. It spiritual problem, or some combination of all of emphasizes the importance of family throughout these. For example, a Hindu Indian American man the life cycle of the individual. Children are experiencing dhat may believe his symptoms of expected to demonstrate respect, support and sac- semen loss and physical and mental weakness are rifice for their parents and ancestors, to care for the result of excessive attachment to sexual desire their parents and as they age, and behave in a way and decide to pursue yoga therapy to help him that brings honor to the family name. While detach from his sexual desire and restrict mastur- Western cultures are more individualistic and bation. He may have pursued traditional treat- autonomy oriented, Asian cultures are more group ments after a dissatisfying experience with a oriented [35]. Some families may be hierarchical psychiatrist who recommended that the patient with the elderly and males holding positions start an antidepressant to reduce the patient’s imbued with greater authority or respect, though 10 An Approach to Mental Health in Asian Americans 183 mothers may be more responsible for the emo- The interdependence of family members tional harmony of the family and have more covert among Asian Americans manifests itself in vari- influence [35]. Asian Americans are more likely to ous ways, one of which is when Asian Americans live in multigenerational families than other ethnic contemplate making major life decisions, such as groups and are more likely to live in larger families choosing a career, buying a home, or selecting a than other ethnic groups [2]. However, within the spouse. Another way in which the interdepen- joint family, Asian American children, even adult dence of Asian families reveals itself is in how children, are often expected to act in accord with families react to the actions of one member of the their parents’ wishes and family cohesion is family. Often behavior of one family member is viewed as valuable [35]. For example, a South considered to be representative of the family as a Asian couple living with the husband’s parents in whole to the rest of society. Families may value Chicago might discuss vacation plans with the academic and occupational achievement of their husband’s parents before making arrangements for children as bringing honor to the family in part for a flight to ensure that they approve. this reason. On the other hand, behavior against the family or cultural values, such as a delinquent behavior, a suicide attempt, being gay or lesbian, Clinical Example or taking a partner from a different religion or eth- As the intake social worker at an urban psy- nic background may be viewed as bringing shame chiatric clinic in New York City, you receive to the family or causing the family to “lose face” a phone call from a Korean man working and lead to conflict within the family [41, 43]. temporarily in the United States. He asks Cultural values of displaying more tempered that you evaluate his wife who has been emotions and family harmony may lead to more very upset about failed infertility treat- indirect or restrained communication between ments. Her infertility specialist recom- family members than in non-Asian American mended that the wife have a mental health families [35, 43]. Additionally, the emphasis evaluation after her last treatment did not placed on respect and obedience to parental work. You arrange an initial meeting with authority can also decrease the likelihood of open the couple. During the first visit with the communication between different generations, couple, the husband describes much of the particularly when there is conflict [43]. wife’s history and the couple’s immigration Acculturation differences between generations as history. The wife occasionally disagrees detailed in the next section in Asian American with the husband but mostly remains silent. immigrant families may also be a cause of prob- The couple expresses how sad they are lems in family communication. Acculturation and about being unable to conceive another enculturation are related concepts. Both reflect child. Because they have been afraid of dis- aspects of the process of change an individual appointing their extended family, neither undergoes when he moves to a new culture. In wife nor husband has discussed their trou- acculturation, this change reflects affiliation with ble conceiving with any family members, the new dominant culture; in enculturation, this who continue to ask them why they have change reflects affiliation to the individual’s old not had a second child. Their extended fam- culture. Dissonant acculturation, which will be ily expects them to have other children by reviewed below, reflects how the process of accul- the time they return to Korea. Both husband turation may cause tension within a family. and wife are worried about returning to live with the husband’s parents and the shame they will face for not having another child. Acculturation and Families The husband agrees that the wife will come to meet with you for the second visit alone. Connections among family members undergo transition as immigrants move to a new culture 184 S. N. Ali and attempt to adapt to the culture. In a process generations [35, 46]. It is also more challenging known as acculturation, the individual adapts with for the elderly to establish a peer group, and a regard to identity, beliefs, and values in relation to grandparent new to the United States may experi- the new dominant culture [44]. Enculturation, a ence an acculturation gap with their children and related concept, functions in the opposite manner an even greater one with their grandchildren. and is a process in which a person strengthens Acculturation is part of the process of making their ties to social norms and values of their cul- a cultural and geographic transition and can lead ture of origin [44]. Hwang has referred to the term to significant intergenerational conflict in Asian acculturation family distancing (AFD) to encap- American families. As will be discussed in the sulate the difference between the parent and child treatment section, this type of conflict can be generation in immigrant households who may quite distressing in families that value loyalty and acculturate at different rates, leading to a differ- harmony and may lead to Asian Americans pre- ence in values and also difficulties in communica- senting to mental health treatment. tion [35, 45]. Other researchers have referred to this phenomenon as “dissonant acculturation” and believe this is particularly relevant in conflict Engaging Asian Americans between parents who may struggle to maintain in Treatment ties to the old culture and children who because of their age and desire to connect with peers may As with any initial encounter with a patient, it is have greater exposure to the new culture [44]. For important for the clinician to understand the example, while the parents in a family may strug- nature of the Asian American patient’s problem gle to learn a new language and understand new and to start to formulate an approach to help the cultural values, the children in a family may more patient with his or her difficulty. Given the impor- rapidly acculturate to the new culture due to tance of family, a mental health clinician or increased exposure to the dominant culture at researcher should be prepared to have multiple school. For example, an immigrant child in mid- family members present for any or all of an initial dle school may learn English more quickly than appointment or assessment [47]. Additionally, his or her parents because of ESL (English as a the clinician may at first consider primarily com- second language) classes. The child may learn municating with the family member in position styles of dress and about current popular music of authority, if this seems in keeping with the from her peers. The child may also see how her family dynamic, even before the appointment non-Asian peers interact with their parents and try and during the appointment itself. In addition to to adopt that style of communication or rebel the usual information gathered in an intake, the against values that she had previously accepted in clinician should strongly consider asking about her family. Areas in which different values may the patient’s and family’s immigration and trauma cause greater conflict include how different gen- history, cultural background, religious beliefs, erations communicate or make choices about patient and family’s acculturation experiences, appearance, sexuality, education, careers, home and the patient and his family’s belief about the ownership, and marriage. etiology of his problem and about what other This acculturation gap can also occur between forms of treatment or help the patient and his elderly relatives that are coming from the country family sought or are seeking. As with other of origin to live in the United States with their chil- patients, traumatic parts of their history, includ- dren. Grandparents may be brought to the United ing migration, violence, abuse, political conflict, States with the idea that they can benefit from bet- and suppression, may require more detailed and ter health care or provide childcare for the family. sensitive inquiry to fully bring to light. Immigration is often alienating for older immi- The hierarchy in the family may be clear to the grants, who likely face greater functional limita- clinician in the first contact with the patient’s tions and language limitations than younger family, whether on the phone or in person, and is 10 An Approach to Mental Health in Asian Americans 185 important to respect in creating an alliance with or family member, to assess his cultural knowl- the patient. A clinician may have to pay extra edge, to ensure that the clinician does not know attention in a meeting with a family and observe others in the patient’s community due to wor- who sits down first and who speaks first and ries about confidentiality, or to find out if the whose opinion most family members defer to. mental health practitioner will judge the patient For example, the husband in a Bangladeshi cou- for their difficulties. Some patients may more ple may first contact the clinician to set up an explicitly express seeing the clinician as a role appointment for his wife and join the clinician model, particularly if the clinician has some and his wife for the initial intake appointment. overlap in background with the patient or fam- When treatment options are given, the patient ily. Like with all patients, some Asian American may look at her husband for guidance before patients, as described later in the stigma sec- expressing an opinion. In another family, the tion, may be fearful about seeing a mental most elderly member of a family may be a health practitioner out of worry that this may mother, and her adult children may defer to her mean that they are insane or that others will find for decision-making. out that they have seen a psychiatrist and this Many Asian Americans may view the clini- will bring on shame for his or her family. cian as an expert or an authority and may feel Some Asian Americans may have limited that it is impolite to express disagreement or English language proficiency, which can pose a ask too many questions of the clinician. Patients challenge for the patient, their family, and the may overtly exhibit deference to authority in a mental health professional. There is very limited variety of ways: calling all clinicians “doctor,” data on the use of professional interpreters and avoiding direct eye contact, profusely thanking nonprofessional (family or friends) interpreters the clinician or bowing, or bringing the clini- or cultural brokers in Asian American patients, cian gifts [47]. Patients may feel more comfort- both in medical and mental health settings. One able with the physician or mental health study of over 2000 Chinese and Vietnamese clinician being authoritative rather than joining immigrant adults at community health centers in with the patient and their family in a more col- the United States found that patients who used laborative manner and sharing decision-making interpreters compared to those who had a clini- with the patient or family. It is possible that cian who spoke the same language were less Asian patients may expect the clinician to act likely to ask questions about mental health [48]. more as the model of the paternalistic healer In this study, patients who rated their interpreters [47]. Patients may covertly express disagree- as high quality were also more likely to rate their ment or dissatisfaction with the recommenda- overall health care as being of high quality [48]. tions of the clinician by remaining silent and The data from this study suggests that Asian not contradicting the physician’s advice or American patients may feel more comfortable accepting a prescription but not filling the pre- with a clinician who speaks the same language scription or taking medications. While silence rather than using an interpreter, particularly for in Western cultures may be viewed as tacit asking about mental health problems. However, it assent, with Asian American patients, silence is very difficult to make generalizations about the can mean dissent [47]. For clinicians, it is use of interpreters, cultural brokers, or language important to not assume that lack of direct eye concordant professionals with the heterogeneous contact is indicative of paranoia, disengage- group of Asian Americans based on only one ment, or social anxiety and also that silence study. Another 2018 study from a community means that the patient completely agrees with mental health center in the Southwest found that the treatment recommendations and will follow ethnic and language matching of Asian American them. Patients or family members may ask patients and counselors predicted completion of a personal questions of the clinician to humanize course of counseling as well as number of ses- the clinician and relate to her as a trusted elder sions attended [49]. Again, this is an area that 186 S. N. Ali merits further exploration. It is not clear that the Psychopharmacology results can be generalized to the heterogeneous members of the group that comprise Asian Studies have shown that Asian Americans may Americans. Additionally, the study authors point benefit from initial lower dosages of medications out that it this kind of matching is not possible in than White populations and may require lower many treatment settings. doses for therapeutic effect. These ethnic differ- I have included some basic guidelines for the ences have been attributed to pharmacogenetic initial encounter summarized in Table 10.3 from differences in the cytochrome p450 system, a my experience and the collective experiences of system of enzymes responsible for metabolizing colleagues working with Asian American psychiatric and other medications. Other factors, patients over the last 8 years in urban settings in such as smoking, diet, age, gender, and use of the emergency room, inpatient unit, research other medications, may also impact effective setting, and private practice. As described ear- plasma levels of psychiatric medications. lier in this chapter, it is important to not make Henderson et al. provide a very thorough review assumptions about the patient and their personal of ethnopsychopharmacology in different minor- narrative based on the general principles in this ity populations [50]. While there is limited data chapter but rather to use these principles as on ethnopsychopharmacology in persons of framework for understanding the patient and Asian descent, it is worthwhile to examine the how their present situation came to pass. relevant findings and consider how these findings may impact mental health research and treatment of Asian American populations. Table 10.3 Ten tips for the initial encounter with an With regard to the cytochrome p450 system, Asian American patient the metabolic activity of particular isozymes in 1. Expect and welcome family participation in the this system has been shown to be lower in initial evaluation, possibly from several generations Koreans, Chinese, and Japanese compared to 2. Ask detailed questions about the patient and Whites [19]. In particular, a third of Asians are family’s health beliefs homozygous for a particular mutation, CYP 3. Ask about what treatments they have tried, both 2D6∗10. This mutation leads to slower activity of Western medical and traditional treatments, and the CYP2D6 enzyme that metabolizes traditional what they are currently doing to improve their condition antipsychotics and tricyclic antidepressants [19]. 4. Obtain the patient and family’s immigration and This indicates that an Asian American patient trauma history with this mutation may need a lower dose of an 5. Plan for the initial appointment to be mostly antipsychotic or tricyclic antidepressant to achieve structured by you and somewhat formal. It will the same therapeutic blood level of a medication likely help the patient feel more comfortable with your authority when compared to a patient of another ethnic 6. Do not be put off by a patient’s limited eye contact backgrounds. Additionally, approximately 20% or deferential manner if this occurs of persons of Asian descent may have a mutation 7. Be sensitive to family conflicts and of CYP2C19 called m2. This mutation causes intergenerational conflicts as a possible reason for 20% of Asians to be poor metabolizers of the ben- the patient’s seeking treatment 8. Remain mindful of the mind body connection as zodiazepine diazepam compared to 3% of White you ask questions and recommend treatment for persons [19]. Another study by Lin showed that the patient both foreign-born and US-born Asian Americans 9. Remain open to the integration of the patient’s responded to lower doses of alprazolam than traditional healing methods and what you Whites [51]. In this study, there was no difference recommend 10. Do not assume that a patient upholds to a in the response to the medication between for- particular religious or cultural belief; make sure to eign-born and US-born Asians, which suggests ask about it! As with every patient, each patient is that the difference between Whites and persons of a unique individual Asian descent was pharmacogenetic [51]. 10 An Approach to Mental Health in Asian Americans 187

Nongenetic factors also impact the activity of levels of medications to assess whether or not a various isozymes of the cytochrome p450 sys- patient is a normal or slow metabolizer after an tem. For example, the activity of isozyme Asian American patient has been on a steady CYP1A2, involved in the metabolism of typical dose of medication for several weeks (Table 10.4). antipsychotics, olanzapine, clozapine, amitripty- With regard to psychoeducation, as with all line, clomipramine, nortriptyline, mirtazapine, patients, it is helpful for Asian American patients and fluvoxamine, can be induced by the con- to know that antidepressants and mood stabiliz- sumption of char-broiled beef and a high-protein ers take weeks to work and antipsychotics take diet, which may be consumed by particular East days to work. Some Asian American patients Asian populations [19]. The activity of another may be more likely to believe that medications isozyme CYP3A4 is notably inhibited by con- should be short term and work quickly, based on sumption of citrus fruits and corn [19]. traditional beliefs [54]. For these patients, it is There may be other differences that account very important to understand the difference for differing response to psychiatric medications between medications that work quickly like in Asians. For example, treatment with lithium in benzodiazepines and stimulants and ones that East Asian populations yields a therapeutic effect they need to remain on for longer to achieve at levels less than 0.8 meq/mL [19]. The author of their effect. Patients may not be familiar with the review, Lin, suggests that this could be due to how psychotropics work and may need psycho- pharmacodynamic factors, factors related to the education that involves reframing the purpose of effect of a specific medication on the target organ. the medications in a culturally sensitive manner. Another study from 1988 examines the differ- For example, in the treatment of a Southeast ences in serum haloperidol and serum prolactin Asian refugee with severe PTSD and depressive concentrations in White, American-born Asian, and foreign-born Asian American volunteers. Table 10.4 Medical class-specific considerations for This study found significant differences between Asian American patients [50, 52] patients of Asian descent and White patients in Tricyclic Start at half of regular both serum haloperidol levels and prolactin lev- antidepressants starting dose els, suggesting both pharmacokinetic differences Watch for toxicity and side and a possible difference in dopamine receptor- effects, even at low doses mediated response to the medications [52]. May need lower doses of therapeutic effect Asian Americans, because of potential slower SSRI, SNRI, and Lacking data in Asian metabolism of medications, may be more sensi- other antidepressants populations tive to side effects of medications or have toxic Haloperidol Lower doses used with effect reactions to medications prescribed at recom- More likely to have higher mended doses [53]. A study of desipramine phar- blood levels than in other populations macokinetics in White and Chinese volunteers Clozapine May have efficacy with lower found higher clearance of desipramine in White dosage (169 mg/day) volunteers compared to Chinese volunteers when May have more risk of controlling for body weight. The authors suggest agranulocytosis that treating Chinese patients with standard doses Atypical Limited data suggests that antipsychotics Asian patients may have for desipramine would put these patients at (olanzapine, higher blood levels than greater risk for toxicity [53]. A general approach risperidone) other populations to prescribing psychotropics to Asian American Benzodiazepines Slower metabolism in Asian patients may be to “start low and go slow” as with (alprazolam, populations diazepam) Higher blood levels than in geriatric psychiatric patients who are often other populations started at half the typical dose of medications and Lithium Lower doses in East Asian monitored closely for and educated about side populations yield therapeutic effects. It may also be worthwhile to get blood levels 188 S. N. Ali symptoms, a clinician may explain that the California, Ohio, Maryland, and Florida showed patient’s symptoms are due to an excess amount that parents who had previously undergone psy- of stress and not due to a brain problem and that chotherapy had more of a positive attitude toward the medications may help the patient eat and their children potentially getting psychotherapy sleep better [55]. compared to parents that had not. Asian Indian mothers were more open than fathers, additionally [58]. As mentioned above, a study from 2018 Psychotherapy demonstrated that ethnic and language match between clients and therapists predicted success- An Asian American patient may expect a more ful completion of psychotherapy, when socioeco- pragmatic or directive approach in therapy ini- nomic status and acculturation were controlled tially due to viewing the clinician as a wise for, in a diverse Asian American outpatient popu- authority figure and may want advice or feel lation [49]. The concept of client/patient match- uncomfortable with an unstructured session. Like ing remains an area that requires additional study with other patients, their openness to participa- among Asian Americans. tion may depend on how much the patient knows Paying attention to the use of defenses like about psychotherapy and its purpose and also with all patients can help the therapist initially how comfortable they feel expressing their feel- determine how to engage the patient, as well as ings and bringing up potentially shameful or sensitivity to family dynamics. In my clinical painful topics. As with any patient, it is worth experience, it has been notable that themes of considering cognitive behavioral therapy as well separation and individuation may present them- as dynamic approaches, depending on the nature selves prominently for adults of Asian American of the presenting problem. CBT approaches to backgrounds due to some difference in emphasis PTSD and group therapy approaches in Southeast on autonomy and individuality in Western and refugees have been very successful, focusing on Eastern cultures. There have been some excellent pragmatic strategies for managing life and also case studies describing the details of different helping patients understand and manage their Asian American patients in psychotherapy [57, symptoms [55]. Additionally some clinicians 59]. Determining a psychotherapeutic approach have also developed psychotherapeutic treat- is very individual specific and will be addressed ments for cultural syndromes, such as a nursing further in the clinical cases section at the end of treatment program designed for patients with the chapter. Hwa-Byung that incorporated drama therapy, music therapy, and group therapy to help patients express anger. This was more effective treatment Inpatient Treatment for the patients than the control condition [56]. Some authors have suggested the use of tradi- A psychiatric hospitalization is a major event for tional stories or parables in psychotherapy with every patient and family. Asian American fami- less acculturated patients who may have less dif- lies may be misinformed or have misconceptions ficulty talking about conflicts or symptoms in about mental health treatment for these condi- displacement [47]. Other patients may be willing tions based on inhumane conditions at treatment and suitable for engagement in a more insight- facilities in their country of origin of their fami- oriented or exploratory treatment and may bene- ly’s country of origin. They may be more likely fit tremendously from it as stated above [57]. to perceive hospitalization as abandoning the Some members of a family may be more open to patient [60]. Families from any cultural back- participating in psychotherapy if they know ground may also feel it is their duty to care for a another family member who has benefitted from family member with mental illness, but the cul- it. A 2016 survey study of attitudes toward psy- ture value of filial piety may lead to care giving at chotherapy of Asian Indian parents in Texas, home being more of a cultural obligation for 10 An Approach to Mental Health in Asian Americans 189

Asian Americans [61]. As in all populations, with Asian Americans in a culturally sensitive Asians Americans will have the same worries way, Park et al. detail the example of a psychia- about diagnosis and prognosis for the patient. trist working with an Asian American psychotic The clinician also has the responsibility of giving patient who sought consultation from a herbalist the patient and the family hope, a realistic prog- about herbal treatments for psychosis to educate nosis, and reassurance that these illnesses are the family of the patient along with the treating treatable. psychiatrist [60]. For example, knowing that a Because many Asian American families are patient with panic disorder incorporates medita- interdependent, it can be very helpful for the tion into her daily life may help a psychologist patient’s treatment to include multiple family consider a wide variety of treatments for over- members in family meetings in the hospital, to whelming anxiety and fear, including mindful- meet with the entire family while the patient is ness-based cognitive behavioral therapy, inpatient and when planning to transition to out- relaxation exercises, dialectical behavioral ther- patient settings for culturally sensitive psycho- apy, as well as the more traditional route of cog- education. Additionally, it may be helpful to have nitive behavioral therapy for panic disorder. regular contact with the head of the family when Mental health clinicians may have a skepti- needed and for the treatment team to consider the cism to nonevidence-based treatment or feelings family as part of the patient as well. It also may of discomfort by the patient’s pursuit of alterna- help with adherence to specifically discuss the tive treatments and may view it as a challenge to purpose of treatment of medications with the their authority or disbelief in science on the patient as well as the family and discuss issues patient’s part. While Asian American patients related to stigma and shame directly in a matter may view the Western-trained clinician as an of fact manner. For example, the treatment team expert or an authority, the clinician has little to can emphasize the biological etiology of mental lose in the eyes of the patient by being open and health conditions and directly state that a mental flexible about alternative methods of treatment illness is not anyone’s “fault.” The treatment and the unique way in which the patient concep- team can also incorporate any relevant comple- tualizes his or her difficulty. A dismissive reac- mentary or alternative treatments to further build tion could be alienating to some Asian American alliance with the patient and family. patients; however, other Asian Americans may not be interested in pursuing traditional treatments at all or may have exhausted them already. Integration of Traditional Medicine If a practitioner is prescribing medications to and Western Approaches a patient, it is important to check with the patient about whether or not they are taking any tradi- Some patients may wish to pursue traditional tional medications, teas, or supplements and to treatments in addition to or instead of their treat- ask about their diet to ensure that there is not ment with their mental health practitioner, any interaction between any of their treatments whether it involves consulting with a shaman for [60]. In the primary care setting, it is important exercising bad spirits, acupuncture, meditation, to include questions about culturally traditional acupuncture, Ayurvedic or root medicine, tai chi, treatments and practices in initial appointment or other traditional treatments. Before suggesting paperwork with questions about the patient’s allopathic psychopharmacologic or psychother- other medications. This is important for a cul- apy, asking about what traditional treatments the turally sensitive approach but also to ensure the patient has tried would be valuable. Furthermore, safe integration of traditional and allopathic some knowledge or willingness to learn more treatments. Also, in the initial visit of an Asian about these treatments will aid the mental health American patient to any medical specialty, surgi- professional in understanding the patient’s prob- cal clinic, or research assessment, the nurse prac- lem more deeply [60]. In an article about working titioner, social worker, or physician should also 190 S. N. Ali consider that somatic symptoms may be a mani- was hoarding his urine and excrement at home festation of a mental health problem or cultural with his physician parents. In this case, the syndrome. patient’s parents may have believed that seeking treatment for their son in a small community would bring about shame to their family, and the Stigma, Shame, and Denial denial of his illness may have helped to preserve their good image of themselves or their son. A As previously described, Asian American popu- family may believe that the illness is because of lations underutilize mental health services com- karma and telling mental health professionals pared to other ethnic populations. Canadian that a family member is ill may reveal that a fam- researchers in a 2017 study found that patients of ily member may have acted badly in a past life. East and South Asian origin with psychosis were This case illustrates that stigma may be felt by more likely to present to the emergency room the family as well as the patient. under involuntary detention when compared to However, while stigma is often perpetuated by patients of White European, White North the society or community that surrounds the American, Black Caribbean, or Black African patient, family members can also perpetuate origin [62]. This suggests that in addition to other stigma by shaming a patient about their illness, barriers to accessing services, Asian Americans not encouraging them to disclose their illness, may delay seeking psychiatric services for them- and criticizing the patient about being lazy and selves or a family member to the point that the not working, for example. A 2015 study of stigma patient’s condition may have become very seri- experiences of Chinese immigrant patients with ous [19]. Additionally, if Asian American patients psychosis in New York City revealed a high prev- may tend to present under more coercive circum- alence of stigma perpetuated by family members stances, the potential for alienation from the of Chinese patients with psychosis. The research- mental health-care system could be quite high, as ers found this finding particularly striking, as contact with emergency psychiatric services can many patients have to rely on family for social be quite scary or overwhelming. Additionally, and economic support and yet feel quite stigma- when mental health is discussed in the primary tized by them [65]. Stigma may also be influ- care setting, aspects of stigma continue to be enced by the age of the individual. Family stigma present in the mind of some patients. A study of was among the significant contributing factors to Chinese American patients in a Boston primary the underutilization of mental health services by care clinic in 2015 showed that, compared to a young Asian American women with a history of prior study, these patients were more likely to depressive symptoms and suicidal behavior, a describe symptoms related to depressed mood particularly high-risk group [66]. One study than somatic symptoms but were more likely found older Korean Americans were more likely hide the cause of these symptoms from others than younger Korean Americans to view depres- compared to the prior sample [63]. This study sion as character weakness bringing shame to the suggests that while Western frameworks for family [67]. Taken together, these studies suggest understanding depressive symptoms may be on that stigma within the family can be a significant the rise, stigma has risen as well. barrier to accessing mental health services for Delays in seeking treatment may be related to Asian Americans. the stigma of mental illness in Asian cultures and For some communities, in which there is a tradi- an effort to ward off shame for the patient and his tion of arranged marriages or family-brokered or her family [64]. For example, a young South unions, like also in the Orthodox Jewish commu- Asian American man with a psychotic illness at a nity in which mental illness is very stigmatized, the city hospital told his treating physician that he idea of revealing that a family member has a psy- had been off antipsychotics for months while liv- chiatric problem may taint marriage prospects not ing at home and was paranoid to the point that he only for the patient but also for their siblings or for 10 An Approach to Mental Health in Asian Americans 191 generations to come [68]. For the individual’s com- nia, or substance abuse, may be more stigmatizing munity, the acknowledgment of psychiatric prob- than others. For example, compulsions related to lems may represent a character defect or genetic hyperreligious obsessions related to cleanliness defect in the person or in the family or person. may be more acceptable in some communities Along this same vein, it may be difficult in the than other psychiatric symptoms. treatment setting to obtain an accurate family history due to stigma. Family members may not tell the clinician about other relatives in the family Intergenerational Conflict with mental health diagnoses. Furthermore, the stigma can be so powerful in families that in More traditional Asian American families may some cases a patient may not have even shared try to minimize conflict within the family or be with his or her spouse that there is mental illness ashamed about revealing the layers of family on his or her side of the family and at times a conflict to the treatment team or professional. In patient may have no idea that he or she has a rela- particular, a parent may be quite distraught about tive with a psychiatric problem. a child making choices that conflict with the fam- This level of shame may lead to difficulty ily’s cultural values and may feel ashamed to dis- accessing treatment for the patient and family cuss this in the health-care setting. A parent may and even may result in a family colluding with manifest their distress in indirect ways, such as the patient’s own resistance to getting desper- somatization or other symptoms, and may pres- ately needed help [60]. For example, a mother ent in the primary care setting. Similarly, children may minimize her child’s hyperreligious manic with aging parents may be extremely uncomfort- behavior of disrobing publicly and giving away able or feel disrespectful if they question an all of his money as a part of a religious ritual not elderly parent’s cognitive abilities or their behav- understood by doctors from a different culture ior to make decisions. They may try to save their and insist that her child does not have an illness. parents shame in front of the professional and The family might support the patient’s wish to be either minimize difficulties or contact the profes- discharged from the emergency room, despite the sional later to be more honest with them. Family patient’s extreme difficulties with functioning. A conflicts may take a great toll on Asian Americans, physician parent may take over prescribing anti- and there is growing evidence to suggest that psychotics for his or her own child and misdiag- conflicts may themselves be a significant contrib- nose them with an anxiety disorder. Families may uting factor to mental health difficulties at differ- even send a mentally ill family member to rela- ent life stages. tives in a different country to live with them in Intergenerational conflict has mental health the hopes of a geographic cure to maintain denial consequences for the Asian American family as a and escape questioning of others in their whole. Greater intergenerational conflict and community. acculturation gap have been found to correlate It is also possible because of shame and stigma with poorer mental health in Asian American col- that patients with trusted relatives or friends who lege students [69]. Asian American families are are physicians or mental health-care profession- particularly at risk of a surge in intergenerational als may have been asked to treat the patient or tension as the younger generation enters adoles- advise on his or her care in an informal way. cence. While in Western culture, adolescence is While this behavior could be seen as culturally associated with rebellion and individuation from acceptable or preferable, for the patient it may be parents, in most Asian cultures, adolescence is difficult to be as open with a person in their social associated with increased responsibilities and con- circle and may make it difficult for the patient to tinued obedience to parental authority with regard get an accurate assessment of their difficulty. It is to important decisions. This gap in values in also possible that in some communities, particu- expectations can be a major source of conflict lar diagnoses, like bipolar disorder, schizophre- between Asian American parents and children and 192 S. N. Ali can lead to tension, depression, anxiety, and sui- hosted the first Asian Symposium on Gay and cidal ideation in children and adolescents [43, 70]. Lesbian Tourism in 2010, Bangkok, Shanghai, One study showed that intergenerational cultural and Manila [75]. Because of values of the impor- dissonance was significantly positively correlated tance of Confucian, Hindu, and Islamic values with increased alcohol use among Cambodian and about gender roles, marriage, and family lineage, Vietnamese youths from immigrant families in homosexuality is still as unacceptable in many Washington State [71]. On the other hand, more families of Asian origin [76]. Families may feel support from adult family members has been neg- that having a homosexual child brings shame to atively correlated with depressive symptoms in the family and makes them subject to social judg- Asian American adolescents [72]. ments. Parents may accept their child’s sexuality Intergenerational conflict can also be very dif- within the family, but they may strongly pressure ficult for parents and for aging adults. One study a child not to be open about their sexuality to showed increased depressive symptoms in Korean extended family. Additionally, while they may American parents with young children. Conflicts accept that their child is gay or lesbian, they still around the child’s social life, expressions of love, may pressure the young adult to marry so that disagreements about proper children’s behavior, they can save face among the extended family and the notion of saving face were most associ- and community. Furthermore, there may also be ated with parental depressive symptoms [73]. pressure on the individual to get married in order Aging Asian American adults also face a similar to have children to continue the family lineage. impact of tension between generations. Analysis Sexual minority Asian Americans may strug- of data from the Population Study of Chinese gle to feel accepted and may be forced to choose Elderly in Chicago demonstrated that difficult between gaining support of the LGBTQ commu- relationships with adult children were correlated nity or their ethnic community, though there are with increased severity of depressive symptoms, increasingly more available resources for whereas more supportive relationships with adult LGBTQ Asian Americans [76]. One study com- children were associated with less severity of pared the utilization of mental health resources symptoms of depression [74]. Given that inter- by heterosexual and homosexual and bisexual generational conflict is associated with psycho- Chinese American, Vietnamese American, and logical distress and depression, this would be a Korean American “1.5-generation” women and good target for mental health interventions across second-generation women found that the sexual the lifespan in Asian Americans. minority women had no more barriers to accessing care than heterosexual women. The researchers hypothesized that this may be because these Lesbian, Gay, Bisexual, sexual minority women may be more open to Transgendered, and Questioning seeking out mental health services because of the (LGBTQ) Asian Americans combined difficulties they face belonging to both an ethnic minority population and a sexual minor- While Asia has made more progress in the last ity population [77]. However, this increased abil- 10–20 years of having more openly homosexual ity to seek out care may also suggest that the populations, individuals who are lesbian, gay, mental health burden is higher on these patients bisexual, transgendered, or questioning (LGBTQ) who belong to multiple minority groups. are still often highly discriminated against, marginalized, and can be subject to violence in Asia. While, in the United States, LGBTQ individuals Racism and Mental Health have found increased acceptance in recent decades, Asian cultures lag far behind in this Asian Americans are subjected to bias and respect. Some areas that have a reputation for aggression due to their appearance, country of being LGBTQ friendly include Nepal, which origin, language, accent, migration history, citi- 10 An Approach to Mental Health in Asian Americans 193 zenship status, and other factors related to stereo- of the value of equality in American society and types about their culture, including diet, clothing, were more likely to recognize when discrimina- customs, marital practices, and style of speech. tion had taken place [82]. Taken together, these Microaggressions related to race have been asso- studies reinforce anecdotal experiences heard in ciated with depression, somatic symptoms, nega- clinicians’ and educators’ offices that bias expe- tive affect, and traumatic symptoms in Asian rienced on a daily basis can erode self-esteem Americans [78–80]. In recent years, more and mental health in Asian Americans. It is research has been devoted to studying microag- imperative that professionals working with this gression as well as ways to cope with racism. A population take these experiences seriously and 2018 study of Asian American and Latin not minimize them when hearing about discrimi- American college students demonstrated an asso- nation from a student, patient, or research ciation between racial microaggression and psy- subject. chological distress. This study found that those affected students who utilized engaging coping strategies, such as turning toward others for sup- Abuse/Trauma port in their social system, mitigated the risk of depression and negative mental health outcomes, As a clinician, educator, or researcher working as opposed to strategies that involved distancing with Asian American populations, it is critical to themselves from others [78]. be alert to histories of trauma to understand one’s Interestingly, another study of foreign-born patient or research subject. There are many sub- Chinese, Vietnamese, and Korean Americans in groups within Asian American communities that Baltimore found that everyday experiences of have experienced traumatic incidents on a wide discrimination were more likely to be associated level including the Vietnam war, repetitive sexual with depressive symptoms than major experi- assault as comfort women in Korea, Japanese ences of discrimination, perhaps due to interment in the United States, human trafficking population-specific factors that may have been for prostitution or domestic slavery, and difficult to tease apart in this study. In this study, Cambodian Civil war, imprisonment, and torture three out of every five subjects reported having under repressive governments [47, 55]. These any experiences of discrimination, and one out of experiences, which may not be easily disclosed every five subjects reported having a major expe- clearly, impact mental health. rience of discrimination [81]. The researchers A 2016 study based on the NLAAS data hypothesized that a language barrier may have showed that Asian immigrant groups, except for prevented some participants from accurately cat- the Vietnamese, with pre-migration trauma, egorizing acts of discrimination toward them as which included political trauma, crime victimiza- major experience of discrimination. tion, physical violence, accidents, life-threatening A cross-sectional study of older Chinese trauma, and vicarious trauma, all were more Americans in Chicago indicated that discrimina- likely to have psychological distress post-migration was statistically significantly associated with tion. This post-migration distress was often expe- depression, independently of other factors, such rienced through perceived discrimination [83]. as socioeconomic variables and personality fac- This study indicates that there is a significant link tors. This study also showed that more accultur- between the experiences of Asian Americans ated older Chinese Americans living outside of prior to immigration and their mental health upon Chinatown with higher socioeconomic status and arrival and adjustment to their new country. acculturation were more likely to report discrimi- Experiences of discrimination in the United nation [82]. From this data, it is not clear if these States may compound traumas in the past of individuals had more contact with non-Chinese these patients. When compared to White, persons and were more likely to be subjected to Hispanic, and Black groups, another study found depression or whether they were more cognizant that Asians who experienced childhood mistreat- 194 S. N. Ali ment and interpersonal violence were mostly patient’s description of their experiences and to likely to report suicidal ideation when compared help the patient understand and contextualize to the other groups [84]. While more research their childhood experiences. needs to be done in this area, it appears that trau- To help the reader synthesize the information matic experiences may put Asian Americans par- in this chapter, the complexities of what was just ticularly at risk for mental health difficulties. discussed is illustrated in these blended cases (to Patients may or may not initiate a discussion protect patient privacy) based on the chapter about these experiences due to shame and stigma, author’s (SA) own clinical work, consultations though they may exhibit some symptoms of with experts, and the cases of colleagues in clini- PTSD or maltreatment on exam (see section Case cal, educational, and research settings. 1). A 2018 study of the impact of 9/11 on Asian Americans indicated that, compared to Caucasians, Asian Americans had a higher preva- Case Vignettes lence of PTSD. The prevalence of PTSD in this population was also higher than that of the first Case 1 responders and civilian survivors from the tow- ers, suggesting a greater vulnerability to PTSD in A 34-year-old Cambodian male presents for an this population [85]. One wonders if the persons assessment of depression as a referral from his in this study had higher levels of trauma in their male psychotherapist who he has seen off and on backgrounds as well. Trauma may also happen in the past 5 years. He was previously treated on an individual level, and patients may feel with fluoxetine and bupropion but felt that his ashamed about discussing these issues with the past psychiatrist was too aggressive in increasing clinician for fear of bringing shame onto their the doses of medications and wants to be only on families. one medication. He has been socially isolated, Traumas common in Asian American house- not eating adequately, and not managing his holds include domestic violence, incest, rape, finances; he is also worried about being judged sexual abuse, physical abuse, and verbal abuse for making too much noise by his neighbor next [47]. A patient may have difficulty identifying door and incredibly anxious about trying to date abuse in the home as abnormal or traumatic and women. After meeting with him and discussing linking this history to their present symptoms. A his case with the therapist, he is started on escita- 2016 survey study of South Asians in America lopram. The dose is increased over 2 months, found that 25.2% of respondents reported a his- until the therapist reaches out to the psychiatrist tory of childhood sexual abuse and 41.2% about the patient’s suicidal thoughts. The patient reported witnessing parental violence and 24% revealed these thoughts to the psychotherapist, described a history of experiencing violence in but not the female psychiatrist. their own adult relationship. This study, among After the patient’s regimen changes to venla- many others, demonstrated an association faxine and the dose is increased in conjunction between suicidal ideation, childhood sexual with the therapist’s ongoing concern about the abuse, and a history of violence in relationships patient’s functioning, the patient again has a [86]. For example, an Indian American patient worsening of symptoms and a severe episode of with depression, promiscuity, and emotional out- suicidality. In this episode he contemplates hang- bursts may not readily identify her mother’s ing himself and takes out a belt. This happens on physical and emotional abuse of her as a child as a day when there is a mix-up about his refill with connected to her difficulties with mood regula- the pharmacy, and he becomes agitated and angry tion and difficulties establishing friendships and and cannot calm himself down. He is without intimate relationships. In these cases, it is up to medication for 2 days and does not reach out to the careful clinician to explore these issues sensi- the psychiatrist. In speaking with his therapist tively and to decipher the meaning behind the about this episode, which does resolve, he 10 An Approach to Mental Health in Asian Americans 195 describes in more detail being locked into a closet therapy and medications. It also helped the psy- at home as a young child when upset and having chiatrist understand why medications may not intense tantrums as a result. He describes having have been as effective in treating this patient, as a flashback about being locked in the closet while PTSD may not have been adequately addressed. he was experiencing medication withdrawal. Also, the psychiatrist wondered if the patient was While each of his five siblings may have experi- less open with her in part because the abuse was enced this punishment, he is the only one in treat- mostly at the hands of his mother, and the patient ment, and his family makes fun of him for being may have felt uncomfortable revealing vulnera- weak. bility to a female authority figure. The psychotherapist also discussed with the patient how being “weak” made the patient feel Discussion like he did not conform to more traditional views of Asian masculinity and also contributed to his Diagnostically, the clinicians both initially feeling like the scapegoat in his family. The two strongly considered diagnoses of major depres- clinicians discussed referring him to a trauma sion and social anxiety disorder, given the group or a trauma-focused psychotherapist who patient’s prior history of depression and neuro- had worked with a refugee population. vegetative symptoms, and also his history of anx- ieties about being judged by the neighbor, as well as his difficulties related to self-esteem in Case 2 dating. In particular, due to the patient’s Asian back- A 45-year-old Bangladeshi woman presents to ground and presentation, the clinicians did ask her primary care physician’s office in tears and about the family’s immigration history and had a with headaches and difficulty eating and sleep- sense of the traumas that the family had experi- ing. Her physician, who has treated her for the enced as refugees to the United States after the past 5 or 6 years, is very surprised as the patient Khmer Rouge seized power. While there was normally seems very well put-together. The some sense of these experiences and their impact patient works for a reputable nonprofit organiza- on the family, the patient minimized his experi- tion. She has a husband who works in financial ence of physical and emotional abuse in the fam- services and a 3-year-old daughter. The patient ily, as this had been “normal” for him. It was also had conceived her daughter through IVF some invalidated by his other siblings and parents. The years earlier, as she believes her husband is a depth of the traumas the patient experienced in closeted gay man, though they have never directly his family, perhaps in part related to traumas discussed this. They have never had a sexual rela- experienced by his parents, made his clinicians tionship but decided to have a child together. consider intergenerational transmission of trauma While she was very depressed before the preg- in his family and how such trauma was perpetu- nancy and throughout the pregnancy, she has ated in the patient’s generation. In his family, been very delighted to be a mother. She notes that there was the belief that the children had it much the problems in her marriage have worsened easier than their parents after immigrating to the since the child was born, and she has not slept in United States. the same bedroom as her husband for the past This leads to the psychiatrist and psychothera- 3 years. Her husband gets upset with her if she pist to consider the diagnosis of post-traumatic leaves the house to get a haircut as he wants her stress disorder as a contributing diagnosis to the to be fully responsible for the child and always patient’s symptoms. They also reflected on what puts his work first. kinds of treatment might be more beneficial for She decided 2 years ago that she wanted to try the patient, including mind-body treatments, like to have another child, which her husband toler- yoga or meditation, in conjunction with psycho- ated but did not really support. She was pregnant 196 S. N. Ali earlier this year but had a miscarriage 5 weeks patient could feel more ashamed or judged. The ago. Since then, she has felt her mood go “off a patient expresses feeling blamed by her husband cliff.” She has been crying nonstop and feels that and particularly her mother, who implied that she she cannot get anyone to understand how badly is weak for being so sad about the miscarriage. she feels. She tried getting comfort from her The patient also feels upset with her mother for mother, who lives in the same city, but her mother linking the miscarriage to her karma. told her to be strong, that the child was not actu- In the end, the internist discusses options for ally born, and that perhaps she deserved this from treatment with the patient, who declines medica- something she had done in her past life. The tions at this time but does agree to go to the emer- patient feels blamed by her husband who was not gency room to get help from a counseling referral. in favor of a second pregnancy. She does not She feels strongly against psychiatric medica- know what to do. She does not want to go to work tions as she believes her family would judge her today and has suicidal thoughts but feels that she for needing medications for sleep or for her sad- would not want to hurt her daughter. ness but does want to speak to someone who can understand her feelings about the miscarriage as well as her difficulties with her husband. Discussion The PCP negotiates with the patient to go to the emergency room to help her find a referral The primary care physician (PCP) is very con- and also ensure her safety and privacy in discuss- cerned about this patient and immediately does a ing her difficulties more in depth. The patient risk assessment. While she promises him that she agrees to go to the emergency room and speaks will not hurt herself right now and denies any with a social worker who gives her a referral list intention of doing so, he asks if she would be for therapists specializing in women’s issues in willing to go to the emergency room to get more addition to information for a South Asian domes- quickly connected to psychiatric services. With tic violence organization, with the hopes that the the patient’s permission, the PCP leaves a mes- patient might be able to find a therapist knowl- sage for her OB/GYN to also let the OB/GYN edgeable about South Asian culture through this provider know the patient’s distress after the mis- resource. The patient declines a referral for a carriage. He wonders if her presentation could be group for women who have faced recent miscar- related to any hormonal dysregulation and the riages, though does feel helped to hear the social withdrawal of IVF medications. worker normalize her feelings of grief and loss The PCP also wonders if the patient is acutely about the miscarriage. depressed, acutely grieving, or having some somatic symptoms as a result of the recent loss and difficulties with her husband. The PCP works Case 3 to find a culturally sensitive way to discuss the patient’s mental health issues with the patient. He A 19-year-old Chinese American woman fresh- frames the patient’s difficulties as the result of the man in college presents to her college mental recent loss that can impact both the body and the health center with her roommates during the win- mind, leading to her physical and psychological ter session. The patient has never been in mental symptoms. health treatment before, but her roommates are The patient is facing various cultural stressors concerned about her, as she has not been sleeping exacerbating her stress and grief, and the PCP and has been behaving erratically and not like tries to engage thoughtfully in a discussion with herself: speaking rapidly, staying out late at night, her before determining a course of action. The and drinking on weeknights. The roommates internist hears how judged the patient feels by her have thought about calling her parents, but they husband and her mother, and does not involve the are hesitant, because the patient has stated that patient’s husband and mother at this time, as the her parents are very strict Christians. Her parents 10 An Approach to Mental Health in Asian Americans 197 have wanted her to come home on the weekends therapist gets the sense that for the patient, as they live within a 2-hour drive from the col- expressing her own desires and having autonomy lege. The parents want her to tutor her younger may be particularly important given her cultural sister in high school and spend time with her and religious strict upbringing. She feels that on grandmother who lives with the family. The some level the patient may be testing out her patient has not been returning phone calls to the autonomy and may need to close off communica- family and has not been returning their text mes- tion with her family in order to do so. The thera- sages. During the first month of the semester, the pist tries to validate the patient’s choices to patient visited home for two weekends, and her experiment but also asks the patient to think parents and sister visited the two other about why her roommates may be concerned weekends. about the changes in her behavior. The patient, The counselor available for walk-in appoint- feeling not judged or criticized by the therapist, ments at the health center obtained this history admits that she has been experimenting with from the roommates and speaks to the patient, drinking and using cocaine when she goes out to who exhibits pressured speech. The patient is parties. While she has been enjoying herself, she annoyed at her roommates for bringing her in to has been more lax about her responsibilities, such the counseling center but is willing to talk to the as going to class. The patient describes having counselor. grown up with a sense of needing to be a “model minority.” In talking more with the patient, the counselor feels less concerned about the patient Discussion having an acute manic episode but does recommend to the patient short-term therapy to explore The counselor is unclear about what is happening her feelings around leaving home and being in a with this patient and has a broad differential diag- less-restrictive environment. nosis that includes bipolar disorder, major depression, a medical problem, an anxiety disorder, a substance use disorder, and/or a separation/indi- Conclusions and Future Directions viduation family-related difficulty. The counselor first asks about the adjustment to college this The population of Asian Americans in the United semester; the patient describes feeling a sense of States is rapidly growing, and their mental health freedom from her family after the first month needs are mounting as well. These needs in Asian when she decided to stop going home as fre- Americans will reach a crisis point if the mental quently. The patient reports having a very strict health field does not grow in its understanding of curfew at home and not being allowed to spend this population. Asian Americans continue to much time with friends outside of high school underutilize mental health-care services, though and church. Of note, the counselor is from an the reasons for this could be further elucidated, African-American evangelical Christian back- despite the increase of research and efforts ground and feels a sense of identification with the devoted to this population by clinicians, research- patient, which she notes. While the therapist feels ers, and educators. that separation/individuation conflicts may not be This chapter has highlighted that there is a lack as pronounced in her own background, she can of reliable data of the incidence and prevalence of appreciate that the patient is caught between a mental health disorders in Asian Americans. This sense of duty and obligation to her parents, sister, missing information makes the task of developing and grandmother and also wanting to explore life targeted interventions to decrease stigma and in college. shame and increase awareness of mental condi- The patient discloses that she has been enjoy- tions quite difficult. A realistic appraisal of the ing staying out late on Saturday nights and sleep- mental health diagnoses and impact of mental ing in very late on Sunday mornings. The health disorders on Asian American populations 198 S. N. Ali is a critical future direction for researchers. 9. Cook BL, Trinh N, et al. 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Aida L. Jiménez, Margarita Alegría, Richard F. Camino-Gaztambide, Lazaro V. Zayas, and Maria Jose Lisotto

Introduction largest and youngest racial and ethnic group. This dramatic demographic shift raises questions The Latino population is increasing at a rate far about the ability of mental healthcare systems to surpassing the capacity needed to understand and address the needs of this rapidly growing and respond to their mental health needs. Latinos diverse population. Interestingly, since the year make up the fastest-growing population segment 2000, there has been a shift in terms of the pri- of the USA, making up 17.6% of the total US mary source of Latino population growth moving population in 2015, from 3.5% in 1960 [1]. The from immigration to Latino births in the USA Hispanic/Latino community is expected to reach [3]. In this chapter, we will use “Latino” and 28.6% (119 million) of the United States (US) “Hispanic” interchangeably, but it is important to population by 2060 [2] making it the nation’s know that “Hispanic” refers to a common language (describing those whose ancestry comes from Spain or Spanish-speaking countries), while A. L. Jiménez (*) Department of Psychology, University of Puerto “Latino” refers to geography, specifically to indi- Rico, San Juan, PR, USA viduals with Latin America origin. In the year e-mail: [email protected] 2000, foreign-born Latinos comprised 40% of the M. Alegría total Latino population in the USA, while in Disparities Research Unit at Massachusetts General 2015, the share of foreign-born Latinos declined Hospital, Boston, MA, USA to 34.4%; alternatively, the share of US-born Department of Medicine, Harvard Medical School, Latinos went from 59.9% in 2000 to 65.6% in Boston, MA, USA 2015 [4]. These opposing trends have begun to R. F. Camino-Gaztambide reshape the adult Hispanic population with obvi- Department of Psychiatry, Medical College of ous consequences on how healthcare providers Georgia at Augusta University, Augusta, GA, USA understand and deliver care. As mental health L. V. Zayas providers, we have a duty to actualize our cul- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA tural understanding of this diverse group, providing care based on a model of cultural humility, M. J. Lisotto Department of Psychiatry, McLean Hospital, tailored to each generation of Latinos living in Belmont, MA, USA the USA. Harvard Medical School, Latinos face inequities in terms of education, Boston, MA, USA socioeconomic status, and access to care, and

© Springer Nature Switzerland AG 2019 201 R. Parekh, N.-H. T. Trinh (eds.), The Massachusetts General Hospital Textbook on Diversity and Cultural Sensitivity in Mental Health, Current Clinical Psychiatry, https://doi.org/10.1007/978-3-030-20174-6_11 202 A. L. Jiménez et al. such inequities are often exacerbated by lan- ing for age and sex; Latinos continue to be less guage barriers. The differences are so striking likely to have a usual place to go for medical that in their report, the Institute of Medicine care compared with both non-Latino White and states that Hispanic Americans “face greater non-Latino Black counterparts. Even when they barriers than any other racial and ethnic group access treatment, Latinos are also less likely to in the U.S.” [5]. Despite the enormous toll that remain in treatment [22] or endorse not having mental health problems exact upon the well- received good quality care [23]. In addition, being of children, adults, and families, dispari- although Latinos tend to present with more ties in access to and adequacy of quality mental severe alcohol use-related problems than non- health services exist for Latinos [6], who are Latino Whites, they are less likely to receive more likely to receive less and inferior mental specialty care and report more barriers to obtain- health services as compared to non-Latino ing care as compared to non-Latino Whites. Whites [7]. A growing demand coupled with a Furthermore, there is evidence showing that high level of unmet needs represents a signifi- Latino men have greater odds of dependence cant challenge in addressing the mental health even at the lowest and moderate levels of heavy needs of this population [7–9]. drinking relative to non-Latino White men and Latino youth make fewer office visits for that among low-level heavy drinkers, Latino ADHD and depression [10, 11] than non-Latino men had twice as high rates of work/legal con- White children and are also less likely to be sequences when compared to non-Latino White identified as having a need for behavioral ser- men [24]. Yet, a dearth of research examining vices when compared to Caucasian and African underlying mechanisms leading to differences American children [12]. Latino adolescents in pathogenesis and illness severity among report lower average scores on antidepressant Latinos and few evidence-based initiatives and counseling knowledge than White teens aimed to address the systemic problems Latinos [13] and lower rates of mental health service use encounter in already existing mental health [14] and are less likely to report receiving assis- services. tance when they endorse suicidal ideation [15]. The purpose of this chapter is to provide Since knowledge about medications and coun- mental health professionals with an overview of seling is associated with willingness to seek the existing literature on various cultural active treatment in adolescents, it is not hard to aspects of Latinos living in the USA so that see how structural barriers to accessing mental they may be able to integrate cultural humility healthcare among Latino youth (i.e., difficulties and sensitivity in their work with this popula- related to health insurance coverage and high tion. This chapter reviews the literature on the cost of mental health services, low wages among prevalence of mental health and substance use Latino parents), coupled with scarce commu- disorders (SUDs) in Latinos, disparities that nity-based psychoeducation and cultural stigma exist in mental health and education among associated with mental health, would lead to Latinos, and other mental health factors perti- problems accessing mental healthcare among nent to this diverse population. Our goal is to Latino youth. provide mental health professionals with a Adult Latinos are more likely than their non- more nuanced sense of this heterogeneous Latino White counterparts to be under- or unin- group and the challenges Latinos face so that a sured [15, 16], and to be poorer [1, 17], are more respectful interaction that takes into account likely to confront language and cultural barriers their cultural beliefs and preferences for treat- [18], and are less likely to have access to exist- ment is fostered. A narrative therapy model will ing mental health services [19–21], Early release be used throughout this chapter when offering data estimates based on data from the 2016 suggestions and recommendations for mental National Health Interview Survey (NHIS) [16] health professionals. This model will be discontinue to show these disparities after adjust- cussed in detail later. 11 Cultural Sensitivity: What Should We Understand About Latinos? 203

Assessing Diversity Among Latinos The term “Hispanic” was created by the US Census to refer to people of Spanish origin liv- The US Latino population is quite heteroge- ing in the USA [30]. In contrast, the term Latino neous in its composition. Latinos living in the emerged from community-based initiatives. The USA come from many parts of the world, term Latino is thought to affirm native, pre-His- including South America, Central America, the panic identity and is preferred by some Caribbean, and North America. Mental health Hispanics/Latinos/as since it is thought to con- professionals need to understand culturally vey a sense of belonging to a diverse group of mediated factors relevant to their patient’s expe- people who speak one or more of the romance rience, including discrete patterns of migration, languages [31]. However, the Pew Research reception in the USA, acculturation experi- Center’s 2013 National Survey of Latinos ences, demographic patterns, and living circum- showed that half of Latinos say they have no stances [19, 25, 26]. Mexico is the largest birth preference for either term but when a preference country among the US foreign-born population; is expressed, Hispanic (33%) is preferred over 63.3% of Latinos in the USA are Mexicans, Latino (15%) by a margin of 2:1 [32]. while Puerto Ricans, the second largest foreign- The term Latino also represents complex and born Latino group in the USA, represent only varied notions of race. According to Santiago- 9.5% of Latino population in the USA [1]. For Rivera [33], most people in the Americas self- example, Puerto Ricans traditionally were more identify as mestizo, a blend of European and likely to reside in the Northeast as compared to American Indian populations. Intermingling of the other Latino subgroups, but recent data Europeans, American Indians, and Africans shows that between 2005 and 2016, Florida’s results in mixed races and cultures, or what we share of the total inflow from Puerto Rico to the refer to as multiracial groups. It is not easy to USA has far exceeded that of any other state classify Latinos according to the categories [27]. Although New York still has the largest provided by the US Census. In a 2011 national population of Puerto Ricans on the mainland, bilingual survey of 1220 Latino adults conducted given increase inflow of Puerto Ricans to states by the Pew Hispanic Center [34], most Latinos like Florida and Texas coupled with a decrease responded that they preferred to use their family’s inflow of Puerto Ricans to New York (31% country of origin (i.e., Puerto Ricans, Cubans, Puerto Ricans lived in New York in 2000 com- Mexicans) in describing their identity instead of pared to 20% in 2016), estimates have predicted pan-ethnic terms (the grouping together and that new surveys gathered in 2017 might well collective labeling various self-sustained show that Florida has become the state with the ethnicities into one all-encompassing group as largest Puerto Rican population in the mainland Latinos) [34]. However, the terms used to [27]. Mexicans are more likely to be younger describe identity seem to be linked to immigrant (18–34 years), live in the West (51%), and have generation. Among foreign-born Latinos, 66% lower levels of education than other Latinos in say they describe themselves most often by their the USA and the US population overall [28]. In country of origin term (i.e., Mexican, Colombian, contrast, Cubans are older (≥65 years) with Dominican), 48% of second-generation Latinos almost half of immigrants from Cuba having say the same, while only 20% of third-generation been in the USA for over 20 years; Cubans also Latinos would describe themselves by their have higher levels of education with one quarter family’s country of origin. Therefore, in of Cubans ≥25 years having obtained at least a accordance with a narrative perspective of bachelor’s degree as compared to 14% of other identity construction and a “willingness to learn foreign-born Latinos living in the USA [29]. from [the] patient” (although some of the Although the term Latino has been used inter- literature uses the term client instead of patient, changeably with the term Hispanic, the creation in this chapter we will use patient), it is important of these labels has different historical origins. that one ask patients how they self-identify and to 204 A. L. Jiménez et al. let them choose accordingly in order to promote psychopathology [44] among Latino youth. the development of a therapeutic alliance. Moreover, Latino youth are more likely than non- Providers also need to be cognizant of the Latino White youth to have interactions with the effect that providers’ implicit attitudes can have juvenile justice system [45] or to have relatives on the quality of clinical care delivered to involved with the criminal justice system [46]. minority patients. Targeting efforts toward Racial/ethnic minority group consistently increasing clinician’s self-awareness of implicit underutilize mental health services [47] even rela- attitudes, as well as decreasing provider’s tive to psychiatric disorder, and differences in per- stigmatization and Latino homogenization, are ceived need may contribute to these disparities necessary if we want to eliminate disparities in [48]. Specifically, given the heterogeneity of healthcare and provide clinical care stemming Latino population, it is important to remember from a model of cultural humility. that each Latino subgroup might understand medical and psychiatric illnesses differently depending on the subgroups’ place of origin, history, Complex Dynamics That Place patterns, and effects of immigration [49]. In the Latinos at Risk for Mental Illness case of Latino youth growing up as a minority in the USA, even the subgroups’ conceptualization There are many risk factors for mental illness that and identification might vary depending on which disproportionately impact Latinos in the USA, Latino subgroup their family identifies with. including poverty, food insecurity, lack of There is a considerable difference between pres- insurance, community trauma, and/or exposure ence of an underlying psychiatric disorder and the to violence [35]. Almost 20% of Latinos live perception that one needs help among Hispanic below the poverty level as compared to almost adults relative to non-Hispanic Whites [50]. 9% of non-Latino Whites. Among Latino children Latinos, especially those with low incomes, often and adolescents, 28% live in poverty, more than interpret symptoms as normal responses to stress- double the rates of non-Latino Whites (12%) ful life situations [51] and they tend to report [36]. Poverty is associated with significant somatic complaints in the face of psychiatric dis- psychosocial and health vulnerabilities [25]. orders [51] which may in turn delay or prevent Food insecurity, also high among those with low realization of need for psychiatric services. socioeconomic status (SES), including Latino An interesting study published in 2018 by children [25, 37], is associated with a heightened Villatoro et al. [48] analyzed a nationally repre- risk of past-year mood, anxiety, behavior, and sentative sample of 14,906 non-Latino White, SUDs [37, 38]. Asian American, Latino, African American, and Furthermore, many Latino children experi- Afro-Caribbean US adults (18 years or older), to ence compounded community trauma or con- examine whether differences in perceived need fronting and witnessing violence in both their for mental health services across populations homes and their neighborhoods [39], which is could be contributing to disparities in service uti- correlated with high rates of mental illness, lization. They also assessed how the intersections including PTSD, depression, adoption of aggres- of race/ethnicity, gender, and socioeconomic sta- sive behaviors, and externalizing behaviors [40, tus affect perceived need. Researchers found that 41]. Acculturation stressors such as discrimina- non-Latino White men were less likely to have tion and cultural conflicts, parental acculturative perceived need for mental healthcare when com- stress, and peer victimization have also been pared to non-Latino White and Latinos irrespec- identified as potential contributors to Latino tive of gender [48] concluding that social and children’s psychosocial maladjustment [42, 43]. economic disadvantage did not seem to be suffi- There is also evidence that difficulties related to cient alone to account for patterns of perceived integration into US culture are stressful for both need. Instead, they recommend recognizing and parents and youth and may increase the risk of adopting intersectional approaches to understand- 11 Cultural Sensitivity: What Should We Understand About Latinos? 205 ing perceived need since this may help uncover affect providers’ delivery of healthcare and social processes that lead to disparities in mental academic performance, they can also impact self- healthcare [48]. image, social development, and overall well- National and school system-specific research being, especially among Latino youth [49]. suggests there may also be racial/ethnic Stereotype threat studies have shown that this disparities in the availability and utilization of extra pressure can undermine the targeted groups’ special education, Title I (programs created by (immigrants, minorities) academic performance the program of education to improve the academic [61] and, especially among youth from minority achievement of the disadvantaged), and remedial groups, even lead to behaviors that directly services that put Latino children at an academic undermine health, such as adoption of unhealthy disadvantage [52, 53]. Nevertheless, educational eating behaviors and subsequent weight gain attainment has been used as a measure of an [62]. Providers must examine their own cognitive individual’s or group’s ability to succeed in the and affective processes during medical decision- USA [26]. According to Ailinger et al. [54] making, since “implicit social attitudes and education can empower individuals and may stereotypes stored in memory may be retrieved buffer against distress and mental illness by automatically without awareness, unintentionally enhancing social status and access to resources. influencing medical care” [5]. In this time of According to data from US Census Bureau, massive advances around media, technology, and Latino high school dropout rate has been telecommunication, mental health providers and declining consistently going from 34% in 1996 to systems should take advantage of technology and a record 10% in 2016 [55] but is still double the utilize media platforms to raise mental health rate of non-Latino White adolescent dropout awareness among Latinos. Messages targeted (5%). Latino college enrollment rates have also specifically to Latino communities providing been on the rise going from 35% in 1996 to 47% bicultural and bilingual resources around mental in 2016 and have reached rates of non-Latino health-based interventions can help reduce Whites but still below Asian rates that remain at stigma associated with mental health disorders 62%. Although Latinos have made important and increase access to care among Latinos. progress over the last two decades, only 16.4% Although the fact that one in four Latinos obtain a bachelor’s degree or higher compared to speaks only English at home [63], language- 37.3% of non-Latino Whites, 55.9% of Asians, or based limitations may serve to constrain Latinos’ 23.3% of African Americans [56]. Low engagement with institutional supports such as educational attainment among Latinos is schools and/or medical care. Limited English associated with many other factors, including proficiency has been linked to poor access to and financial stress, acculturative stress, andtreatment of mental health disorders [64]. discrimination [57, 58]. Another factor deemed According to Knight et al. [65], a substantial instrumental to low educational attainment proportion of Latinos are either not fluent in among many Latinos is the necessity of leaving English or feel more comfortable speaking in school to obtain work that can financially support Spanish: 30% of Latinos report difficulty in their families [59]. The absence of Latinos in communicating with their healthcare providers leadership positions creates a self-perpetuating [66]. According to Pippins et al. [64], insured cycle: fewer Latinos serve as role models, and Latinos with poor/fair English language profi- fewer young Latino scholars aspire to obtain ciency are more likely than those with good/ postsecondary education [60]. excellent proficiency to report not having a regu- Another complicated problem that affects lar source of care or lacking continuity of care. minorities’ access and/or continuation of According to the AMA Journal of Ethics [67] healthcare services is stigma and stereotypization, “patients with limited English proficiency (LEP) often causing distrust toward healthcare systems are among the most vulnerable populations.” and individual providers. Stereotypes not only Patients with LEP consistently receive lower- 206 A. L. Jiménez et al. quality care than English-proficient patients: Latinos and other minority populations are they have more difficulties understanding treat- more likely to reside in structurally and ment plans and disease processes and experience economically deprived neighborhoods [75, 76]. higher rates of medical errors resulting in physi- These social and contextual factors influence cal harm [68]. Adult patients and/or parents of and/or determine the life circumstances of child patients who have limited English profi- Latinos and place them at risk for poor health ciency (LEP) report that the absence of Spanish- outcomes and healthcare services. Myers [77] speaking staff members is responsible for their argues that socioeconomic status (SES) is the poor medical care, including misdiagnosis, inap- most important factor underlying racial and propriate medications, and unnecessary hospital- ethnic disparities in health because it leads to izations [69]. LEP parents are more likely to differences in material and psychological report poor communication with healthcare pro- resources, environmental and behavioral risks, viders than English-proficient parents [70, 71]. and differences in access to healthcare. However, LEP can also impact the delivery of educational Myers also recognizes that disparities are the services among racial/ethnic minority families result of a complex interaction of factors that [72]. Evidence suggests that limited English flu- include poverty and minority status [77]. ency is associated with parental avoidance of Therefore, an intersectional approach considers school meetings [73] and/or written communica- the interaction between SES and the social and tion from school. Teachers and school staff can contextual factors that specifically influence and/ sometimes misinterpret the lack of parental or determine the life circumstances of Latinos, involvement in the school system or academic helping providers understand and more effectively performance of Latino children as them not recognize the elevated risk for poor health being interested or supportive of their children’s outcomes and healthcare services among Latinos. academic achievements. However, it is rare that lack of parents’ involvement is in fact stemming from an uncaring or unsupportive parent but, Prevalence of Mental Health more often than not, related to other sociocul- and SUDs in Latinos tural aspects affecting how Latino parents view their role within the school system. In fact, fac- Eight population-based epidemiological studies tors such as parent’s unfamiliarity with the sys- conducted in the USA and Puerto Rico from tem, language barrier, and even Latino’s cultural 1983 to 2003 have examined the prevalence of value of respect and deference toward authority psychiatric disorders among adult Latinos. These figures have been attributed to lack of parental studies include the Los Angeles Epidemiologic involvement [74]. Ceballo et al. [74] evaluated Catchment Area Study (LA-ECA), the Puerto the relationship between parental involvement in Rico Epidemiologic Catchment Area Study low-income Latino families and academic out- (PR-ECA), the Hispanic Health and Nutrition comes and found that adolescents that had heard Examination Survey (HHANES), the Mexican parental stories describing their own struggles American Prevalence and Services Survey with poverty and immigration had an increased (MAPSS), the National Comorbidity Study desire to succeed academically and give back to (NCS), the National Comorbidity Survey- their parents. Therefore, if we recognize that an Replication (NCS-R), the National increase in Latinos’ parental involvement within Epidemiological Survey on Alcohol and Related the school system can incentivize and promote Conditions (NESARC), and the National Latino children’s interest and efforts to succeed aca- and Asian American Study (NLAAS). Please demically, we need to ensure that the next gen- consult Canino and Alegría [43] for a thorough eration of educators promotes an environment of review of these studies. What follows is a brief support, collaboration, and multiculturalism review of the important findings of these studies. within the school system. There are significant differences in the prevalence 11 Cultural Sensitivity: What Should We Understand About Latinos? 207 of mental health and SUDs among adult Latinos identify protective or risk factors playing a role in as compared to non-Latino Whites. After the health of Latinos. Using data from this study, adjusting for sociodemographic factors, evidence Perreira et al. [84] performed logistic regressions from most research suggests that Latinos in the to model the risk of moderate to severe symptoms USA seem to be at lower risk for most psychiatric of psychological distress, depression, and anxiety disorders as compared to non-Latino Whites as a function of years in the USA. Perreira et al. [78]. For any lifetime disorder, 29.7% of adult findings were consistent with findings from Latinos meet criteria as compared to 43.2% of NLAAS; higher rates of moderate to severe non-Latino Whites [78]. Lifetime prevalence symptoms of psychological distress, depression, rates for any SUD are reported to be 11.2% and and anxiety were associated with participants’ 17.7% for Latinos and non-Latino Whites, longer exposure to the USA; however, this respectively. However, when Latinos are stratified association varied by Latino background. For by nativity (foreign-born or US-born Latino), example, foreign-born Puerto Ricans had the US-born Latinos are at significantly higher risk highest rates of moderate to severe symptoms of for all lifetime disorders (37.3%) [78] as psychological distress, depression, and anxiety, compared to their foreign-born counterparts but after adjusting for factors such as perceived (23.5%). This has been labeled the immigrant discrimination, perceived US social standing, paradox. This means that Latino immigrants and size of close social networks, there were no have better overall mental health than both their significant associations between years in the US-born Latino counterparts and non-Latino USA and depression for Puerto Ricans. There Whites [79–82]. Despite acculturative stress, was also a significant positive association poverty, discrimination, and other risks associated between years in the USA and anxiety among with the development of mental health disorders, foreign-born Dominicans. On the contrary, foreign nativity seems protective against Central Americans (i.e., Guatemala, El Salvador) psychiatric illness. Alegría and Woo [21] found appeared to have improvement in their mental that when Latinos are disaggregated by ethnicity, health (i.e., lower risk of depression and anxiety the immigrant paradox is observed only among symptoms) the longer they lived in the USA [84]. specific ethnic groups, with specific disorders. Authors hypothesized that some Central For example, Mexicans retain protective factors Americans might have a different experience associated with foreign-born nativity for compared to other Latino immigrants, after depression, anxiety, and SUDs, while Puerto receiving asylee/refugee status in context of Ricans do not. Furthermore, US mainland-born emigrating from countries torn by war and natural Puerto Rican females report higher rates of disasters, which could in turn improve their generalized anxiety disorder (GAD) (11.6%) experience in the USA and subsequently improve than other US-born female Latina groups. Puerto their mental health with years spent in the Rican female migrants also have higher rates of USA. Consistent with findings listed above, PTSD (9.0%) than any other immigrant Latina Perreira et al. found that US mainland-born groups as well. Puerto Ricans had higher rates of moderate to The Hispanic Community Health Study of severe symptoms of psychological distress, Latinos (HCHS)/Study of Latinos (SOL) or depressive symptoms, and anxiety when HCHS/SOL [83] is a multicenter, community- compared to other US-born Latinos. These results based cohort study of 16,000 Hispanic/Latinos in clearly demonstrate that the relationship between the USA aged 18–64 years interviewed between exposure to the USA and mental health varies by 2008 and 2011; the majority of the participants Hispanic/Latino background. Despite dramatic had migrated to the USA in adulthood at age 20 differences in Latinos’ economic and social or older. The objective of this study was to collect circumstances (i.e., education and citizenship), information on the health status and disease epidemiologic data evidences similarities in burden of Latinos living in the USA and to lifetime psychiatric prevalence estimates across 208 A. L. Jiménez et al.

Cubans, Mexicans, and other Latinos (i.e., South schools in the USA. Most recent data from the Americans). However, these averages mask some 2017 YRBS showed that in the last 10 years, less differences across sub-ethnicity by nativity and Latino youngsters have experienced persistent gender. Indeed, mental health professionals feelings of sadness or hopelessness, 33.7% in should be cautious when working with this 2017 compared to 36% in 2007. However, Latino diverse population and avoid generalizations [21, youth continue to be the group with the highest 85] that do not take into account immigration percentage of youngsters experiencing persistent status, gender, and age differences. sadness/hopelessness compared to 30.2% non- Among youth (ages 13–17), data from the Latino White and 29.3% of Black students [90]. National Comorbidity Survey Replication Furthermore, the percentage of Latino students Adolescent Supplement (NCS-A) [86] showed who seriously considered attempting suicide that Latino youth were less likely than non- increased significantly from 2007 (15.9%) Hispanic White youth to receive services for through 2017 (16.4%), as did the number of severe ADHD. Results from NCS-A also showed Latino youngsters who made a suicide plan that despite having higher rates of mood and (12.8% in 2007 to 13.5% in 2017). And even anxiety disorders, Latino adolescents were less though Latino students continue to have a higher likely to receive treatment compared to White rate of suicide attempts compared to non-Latino children. Unfortunately, recent data [87] White students (8.2% vs. 6.1%), there was no continues to sustain previous research showing significant change in suicide attempt rates that White youth aged 5–21 is still more likely to compared to 2007 rates [90]. This data shows that initiate treatment for almost all mental health even though mental health systems targeting conditions compared to Latino youth. The youth in the USA have been put in place for over NCS-A used a measure of aggregated disorder a decade, Latino students continue to be the severity that represented the highest severity group that struggles the most. These concerning level within the disorder type (i.e., externalizing, rates demonstrate the need for mental health- internalizing), using a count of lifetime symptoms based interventions specifically directed toward and questions about functional impairment. Latino youth focused on both US-born and non- Evidence from the NCS-A and multiple sub- US-born Latinos but keeping in mind the sequent studies suggest that the immigrant para- immigrant paradox and how this might affect dox exists for Latino youth. Immigrant Latino different Latino youth subgroups. youth, for example, are less likely to engage in risky sexual behavior and substance use than their US-born Latino peers [88]. Maintaining cul- Biomedical Considerations tural ties with traditional values may be protective for Latino youth, underscoring the importance Selected Genetic and Environmental of embracing and promoting multiculturalism Studies in Hispanics among adolescents from minority groups while helping parents recognize differences in levels of Genetics have been noted to play an important acculturation even among members of the same role in the transmission and phenotypic family. expression of several psychiatric disorders The Youth Risk Behavior Surveillance System (including attention deficit hyperactivity disorder, (YRBS) was developed by the CDC in 1990 to bipolar affective disorder, Alzheimer’s disease, monitor health behaviors that contribute markedly schizophrenia, and alcohol abuse), though they to the leading causes of death, disability, and may vary among specific ethnic groups within social problems among youth and adults in the Latinos [91, 92]. For schizophrenia, the USA [89]. This national survey, conducted every contribution of genetic factors in the general 2 years, provides data representative of ninth population has been estimated to be between through 12th grade students in public and private 60% and 85% and genes 6p22–p24, 1q21–q22, 11 Cultural Sensitivity: What Should We Understand About Latinos? 209

13p32–p34, and 22q11–q12 have been the most the vulnerability of this population to substance frequently implicated [93]. In a study conducted disorders. Risk factors identified in this study by Escamilla et al. [92] among families with a included: male gender, residence in the USA, diagnosis of schizophrenia, schizoaffective immigrant status from Mexico, history of a disorder, and/or other psychotic disorders, gene depressive disorder, and unemployment. 17q21 was found to contribute to its development in adults from Central America even though it is not associated with schizophrenia in the general Psychotropic Considerations population. Several studies have reported an association All psychotropic medications require approval between the apolipoprotein E-e4 genotype from the Federal Drug Administration (FDA) (APOE-e4) and Alzheimer’s disease (AD). Per [100]. However, many have expressed the Blennow et al. [94] this genotype is associated concern that minorities are underrepresented in with a threefold risk increase of developing AD research evidence presented to the FDA for in heterozygote carriers and a 15-fold risk approval. A review of drug applications submitted increase in homozygote carriers. Similarly, a to the FDA between 2013 and 2015 noted study in Texas showed that Mexicans had a lower underrepresentation of racial and ethnic age on onset and more depressive symptoms than minorities in the clinic trials [101]. This obviously non-Latino Whites [95]. Livney et al. [96] found raises concern because evidence shows that that Latinos (87% of cohort were Puerto Rican) minorities, specifically Latinos, respond had an earlier age onset of AD, exhibited more differently to certain medications, both in terms cognitive impairment, and experienced greater of effectiveness and tolerability. The same issue severity of symptoms than African Americans led to the 2012 FDA Safety and Innovation Act and non-Hispanic Whites. Interestingly, the (FDASIA 907), through which US Congress Latino carriers of APOE-e4 did not develop AD required the FDA to report on the diversity of earlier than the noncarriers, which contradicts the participants in clinical trials and the extent to observation that African American and non- which safety and effectiveness data is based on Hispanic White carriers typically develop the demographic factors such as sex, age, and race. disease earlier in life [96]. It is now widely In a double-blind randomized trial of Latino and accepted that Latinos show an earlier age of onset non-Latino White patients with acute mania, of AD compared to White non-Hispanics [97] Tamayo et al. [102] found that Latino patients which cannot be fully explained by APOE-e4 responded equally as well to olanzapine (atypical carrier status. Even though Latinos tend to be antipsychotic) and haloperidol (typical clustered into one group, understanding the antipsychotic), while non-Latino Whites reported significant differences between subgroups might a better response to olanzapine. The side effect help differentiate the roles that genetic factors profile of these medications also differed between and other determinants of health play in the both groups; Latinos experienced more weight prevalence, severity of symptoms, and treatment gain and somnolence after taking both of AD among Latinos. medications and reported more tremors with Environmental factors can be important to haloperidol than their non-Latino White promote or suppress gene expression [98]. A counterparts. In addition, non-Latino Whites study conducted in the Southwestern USA, scored higher on the Barnes Akathisia Scale and Mexico, and Central America by Jimenez-Castro Abnormal Involuntary Movement Scale [102] et al. [99] found that Latinos with schizophrenia than did Latinos. Implications are that in living in the USA were more likely to have a Caucasians group you might want to favor SUD than their Latino counterparts residing in olanzapine over haloperidol due to better Central America or Mexico. This suggests that response, but in Latinos preference might be environmental factors in the USA may increase focused on side effect profile and cost. 210 A. L. Jiménez et al.

Evidence suggests that it is prudent to tailor among others, can provide aid in complicated or treatment strategies to individual patients and to nonresponsive patients and can provide informa- take the patient’s ethnicity under consideration tion on who might be at higher risk of certain side when developing a treatment plan involving the effect profile; nevertheless, they are still not rec- use of psychotropic medications. ommended for routine clinical use [106].

Pharmacogenomics Psychopharmacological Adherence

Pharmacogenomics refers to the use of a patient’s One of the most frequent causes of treatment fail- genetic profile to identify which medications ure is psychopharmacological nonadherence. In a have the highest probability of producing a literature review of 21 studies that included desirable response with the fewest number of Latino populations, Lanouette et al. [107] found side effects [103]. One area of focus is the that the rate of nonadherence to psychotropic cytochrome P450 (CYP450) system, an medication was 44% among studies that include enzymatic system in the liver responsible for the only Latinos and 40% in studies that included metabolism of various medications. Over 50 of multiple ethnic groups. In contrast, the these enzymes have been described in the nonadherence rate for non-Latino Whites was literature. One of these enzymes, CYP2D6, is 30%. This represents an effect size difference of responsible for metabolizing many of the 0.64, suggesting a medium to large difference psychotropic agents, including haloperidol [104]. between the Latino and non-Latino Whites in A variety of genetic polymorphisms found in medication nonadherence. Risk factors for humans affect the efficacy of these enzymes. nonadherence in these studies included substance Geneticists have categorized these polymor- abuse, barriers to access of high-quality phisms according to their ability to metabolize healthcare, lack of health insurance, and limited drugs as poor metabolizers (PM), intermediate family support [107]. Protective factors metabolizers (IM), extensive metabolizers (EM), associated with better adherence were higher or ultrarapid metabolizers (UM). Many studies SES, older age, greater family instrumental and have shown that individuals with the CYP-2D6 financial support, being married, having public or poor metabolizer (PM) polymorphism are at an private insurance, being proactive in one’s care, increased risk of having higher blood serum and having made at least eight visits to a therapist. haloperidol levels with an associated increased An important finding in this review was that incidence of side effects [104]. The frequency of nonadherence to treatment predicted worse these polymorphisms varies among ethnic outcomes. groups. For example, approximately 10% of In a qualitative study of Latino immigrants, Caucasians and Hispanics are poor metabolizers, patient compliance with antidepressant treatment while only 2–4% of African Americans and 1–2% was positively influenced by having a good of Asians are poor metabolizers. As such, relationship with medical providers, having pharmacogenomics may offer another way of tai- previous experience with depression and its loring efficacious treatment to individuals. treatment, receiving family support, holding Clinicians should be aware that treatment positive expectations of treatment effectiveness, response is influenced by a myriad of factors, in and having cultural values that promoted which family history of antidepressant response adherence such as “luchar” (persevering despite has been found to be an important and useful one difficulty), “poner de su parte” (do one’s part), [105], therefore highlighting the importance of and religious faith [108]. Furthermore, one third “old tech” good history taking. In addition, the of Latinos have been shown to discontinue taking availability of pharmacogenetic support tool like antidepressants, and 18.9% did so without input GeneSight, CNSDose, IDgenetix, and Genecept, from their physicians [109]. Saloner and Cook 11 Cultural Sensitivity: What Should We Understand About Latinos? 211

[110] found that Blacks and Hispanics were less lack of insurance, institutional barriers, and a likely than Whites to complete publicly funded lack of skilled providers who are culturally sen- substance abuse treatment. This was explained by sitive [20, 21, 26, 65, 115, 116]. Many scholars differences in SES, unemployment, and housing have also attributed mental health service dis- instability. Finally, Kopelowicz et al. [111] found parities to discrimination [117–119], while lack that educating all family members on medication of insurance has been associated with poor compliance significantly enhanced treatment access to care. Per data from the 2015 American outcomes and accounted for one third of the Community Survey [1], uninsured rate for reduced risk for inpatient psychiatric Latinos was almost 20% (19.7%), which is hospitalization. Interestingly, a study among more than double the national uninsured rate Latinos with a diagnosis of schizophrenia found average (9.7%). There are studies showing that that a greater proportion of Latinos with LEP Latinos have a record of receiving insufficient were adherent to antipsychotics compared to quantity and quality of care even when insur- English-proficient Latinos with schizophrenia ance availability is not a factor [113]. Not only [112]. do Latinos report low levels of access to care; they also have high rates of dropout and missed appointments and poor medication adherence Mental Health Disparities [120]. This has been attributed to linguistic incompatibility between clinicians and patients Even though Latinos are the largest ethnic minor- [66] as well as to a dearth of available treat- ity group in the USA, their mental health needs ments and personnel who can provide cultur- and service utilization patterns do not reflect their ally sensitive care. Vega et al. [121] have size. Latinos have less access to mental health- stressed the importance of considering the role care and are less likely to receive mental health of language in the acculturation process, the services than non-Latino Whites [20, 21]. patient’s symptom presentation, and the level of According to the 2011/2012 National Survey of patient disclosure to their therapist. Per Vega Children’s Health [21], only 53.8% of Latino et al. [121] problems in detection and diagnosis children (ages 2–17 years old) needed and due to language barriers can result in less effec- received mental health services/counseling in the tive and more costly treatment, clinical error, past 12 months, compared to 68% of White frustration of patients, and greater burden on children who needed and received mental health caregivers [122]. Another important impedi- services/counseling in the last year. Conversely, ment for Latinos to access mental health ser- 46% of Latino youth needed but did not receive vices, especially when it comes to seeking mental health services/counseling within the past mental healthcare for their children, is the fear 12 months, versus 31.9% of White youth who did that immigrant parents experience around their not receive care despite requiring it during the legal status and the possibility of their children same period. being taken away from them. The National Healthcare Disparities Report Language plays an important role in obtain- [6] showed that Latinos are less likely to have ing informed consent from a patient. Language received needed care for substance abuse treat- barriers, unfortunately, prevent Spanish- ment than their White counterparts [113]. speaking Latinos from accurately understanding Furthermore, Vega and Alegría [114] note that written information that is part of an informed Latinos are more likely to receive services that consent. An important task in the evaluation of fail to meet their needs. Potential explanations any patient is assessing his or her capacity to for these disparities and for mental health prob- understand and make a volitional choice. There lems among this population include discrimina- are four criteria that a provider should consider tion, acculturative stress, poor language when evaluating a patient’s decision-making proficiency, low SES, lower educational level, capacity: (1) the patient’s ability to understand 212 A. L. Jiménez et al. the information about his/her treatment, (2) the In addition, Latino gender roles have tradi- patient’s ability to grasp what the information tionally associated Latino women with help- means and how it relates to his/her diagnosis and seeking behaviors. Studies have consistently available treatment options, (3) the patient’s shown that Latino women use more health and ability to understand the treatment options, and mental health services than men [128, 129]. The (4) the patient’s ability to communicate his or low utilization of mental health services and low her decision consistently [123]. For a patient to treatment adherence by Latino men has been make an informed decision regarding his/her associated with their traditional perception of treatment, it is important that he/she fully under- masculinity, or machismo [130]. Males who seek stand the information transmitted [124]. If the mental health services are often interpreted as patient has difficulty understanding the language being weak and unable to protect their families. in which the information is transmitted, he or she To reduce such barriers to accessing care, might not be able to fully comply with the therapists should explore the barriers placed by requirements needed to make an informed deci- traditional gender roles, particularly among their sion. As previously mentioned, a substantial pro- male patients. The narrative of strength and portion of Latinos are either not fluent in English protectiveness of the family should be included or feel much more comfortable speaking in in the positive reframing of seeking treatment. Spanish. If patients cannot communicate their For example, when a male Latino patient health problems in an accurate way, providers expresses his reluctance to receive help and may make erroneous diagnoses and/or treatment instead solve his family’s problems on his own, a decisions [23]. A study conducted by Baker et al. culturally sensitive therapist could emphasize [125] involving 467 native Spanish-speaking his/her patient’s need to protect his family by the and 63 English-speaking Latino patients in a patient getting involved and involving his family public hospital emergency room setting found in the treatment process. The clinician can that patients who did not speak the same lan- reframe the male’s involvement in treatment as a guage as their providers had poorer treatment sign of both strength and courage. adherence as compared to those patients who spoke their provider’s same language. To decrease the language barriers, present between Ethnic Matching patients and providers, some researchers have suggested using professional medical transla- Ethnic matching refers to the matching between tors [126, 127]. Per a study conducted by patients and clinicians in psychotherapy by their Ginde et al. [126], although 11% of patients ethnicity. Ethnic matching has had mixed results treated in an Emergency Department (ED) and appears to be a complex, multifaceted issue required an interpreter, only 4% received the [131]. However, ethnic matching has been service. Among those Spanish speakers who associated with increased use of community had interpreters, it was found that they had mental health services and a reduction of higher rates of primary care follow-ups and emergency services. In a study conducted in lower rates of return to the ED in the next Australia by Zyguras et al. [132], the investigators 30 days. As such, it is recommended that profound that when patients of an ethnic minority viders who have limited knowledge or do not were matched with clinicians from the same speak the patient’s language use trained medi- ethnic background, these patients had better cal interpreters to deliver effective treatment. outcomes. The patients who were ethnically Furthermore, it is not recommended that pro- matched with providers were noted to have viders use family members, especially chil- longer retention in care [133] and greater dren, as interpreters, as this has been associated frequency of contact with community care teams. with a disruption of the family hierarchical In addition, contact with crisis teams occurred balance [26]. less often and lasted less time with patients who 11 Cultural Sensitivity: What Should We Understand About Latinos? 213 were ethnically matched. Furthermore, ethnic Smith [138] encourage therapist alignment with matching has also been linked to achieving the patient’s worldview instead of focusing on culturally sensitive treatments [134, 135]. ethnic matching. The collective experience of However, there are important limitations to these authors encourages both therapist alignment ethnic matching among Latinos. Despite research with the patient’s worldview and culturally suggesting the importance of ethnic matching adapted treatments which take language into and culturally adapted treatments which take consideration. language into consideration, Bernal et al. [136] pointed out the shortage of Latino mental health professionals in the USA, highlighting the lack of Narrative Therapy interventions developed for Spanish speakers. Second, there is a shortage of Latino mental A narrative framework has been used through- health professionals in the USA [33, 137]. out this chapter when offering suggestions and On the other hand, a meta-analysis conducted recommendations for mental health providers. by Cabral and Smith [138] with Latino patients Narrative therapy was developed by Michael and patients of other ethnic minority groups White and David Epston in the 1980s and found that ethnic matching yielded mixed results. emphasizes the importance of the use of lan- These authors assessed three variables related to guage in shaping people’s realities [139]. This racial/ethnic matching including: (1) the patient’s narrative framework is based on Michel preference for a therapist of his/her own race/ Foucault’s philosophy that dominant discourses ethnicity, (2) the patient’s perception of his/her of society which objectify and dehumanize indi- therapist across racial/ethnic match, and (3) viduals belonging to marginalized or oppressed therapeutic outcomes across racial/ethnic match. groups ultimately become internalized truths for The investigators of this study found a moderate the future generations of individuals belonging effect size for the first two variables, indicating to these groups [140]. He emphasized that it is that patients tend to prefer and perceive a therapist through story and language that individuals who of their own race/ethnicity more positively than belong to distinct cultural groups transmit mes- therapists of other races/ethnicities. In terms of sages about social norms and the meaning of assessing therapeutic outcomes, however, racial/ various culturally constructed concepts, includ- ethnic matching did not reveal any benefit, except ing gender, class, and mental health, to its mem- for African Americans, who benefited in all three bers. According to this framework, there is no areas. More specifically, African Americans such thing as “reality,” but, instead, an interpre- preferred to be matched with African American tation of reality that is weaved into a narrative therapists, they evaluated their therapist more construction. Therefore, a narrative that conveys positively when they were matched, and they how people perceive themselves and their situa- seemed to achieve better outcomes when matched tion is thus “constructed” through culturally by race. Interestingly, even though Latino patients mediated social interactions [141]. Therefore, express the preference that their therapist be their narrative therapy focuses on the ways in which same ethnicity, there was no significant difference individuals construct meaning and is organized in terms of their perception of the therapist or on according to two organizing principles: personal clinical outcome whether they were matched. narrative and social construction. As previously Cabral and Smith [138] conclude that patients mentioned, a narrative therapist would explore might prefer a therapist of their own race/ those internalized narratives of his/her patient ethnicity because of the belief that their therapist that are saturated with problems and reflect the might share their same worldview; however, once dominant narrative of his/her patient’s society. they start treatment, ethnic matching does not The aim of the therapist is to ultimately help the affect their evaluation of the therapist and to their patient separate himself/herself from these overall clinical outcomes. In sum, Cabral and problem-saturated narratives that are replete 214 A. L. Jiménez et al. with destructive cultural assumptions and help General Latino Characteristics him/her create a more constructive narrative. By and Other Mental Health Factors questioning these assumptions and challenging negative internalized stories of discrimination There are a few general Latino characteristics and inequality, narrative therapists enable that should be considered when working with this patients to become active authors of their lives. diverse group in a clinical setting. In this chapter, Some of the techniques that are used to decon- we will provide a review of many Latino- struct negative narratives and construct positive associated traits but understand that it may come ones include externalization, reframing, use of across as overly reductionist and/or stereotypical. metaphors, and the identification of unique out- See Table 11.1 for a synthesis of the differences comes. As previously mentioned, the Latino between Latinos and non-Latino Whites [25, 26, population is composed of many cultures, races, 31, 143, 144]. As noted, despite their historical backgrounds, immigration histories, heterogeneity, Latinos share many commonalities, and acculturation processes, all of which sug- including the use of Spanish as a common gest that a narrative approach is imperative for language and religion, and most share similar mental health providers to understand in order cultural values, which will be discussed below. to develop cultural sensitivity toward this group. The stories or narratives resulting in immigration to the USA (reasons for and context of immi- Acculturation and Acculturative gration such as political asylum and financial Stress motivations) play an important role in adapting to the host culture [65]. A Latina who is not keen on Acculturation and acculturative stress are widely migrating to the USA following her husband’s debated concepts since their meaning and job relocation, for example, will interpret and assessment lacks methodological uniformity [25, process her experiences and adaptation in a mark- 145, 146]. These traits, however, are generally edly different manner than another person who associated with language proficiency (poor or immigrates as a political refugee or as an undocu- limited proficiency has been related with more mented individual. Therefore, exploring the acculturative stress), years living in the host patient’s migration history and acculturation country, perceived discrimination in the host experience will help both the therapist and the country, cultural compatibilities, and immigrant family’s “external cultural landscape” [31, 27, commitment to culturally mediated values and pp. 19–20]. Furthermore, the migration experi- behaviors deemed protective, such as familial ence of Latinos from different countries may cohesion. According to the immigrant paradox, vary dramatically because of the social and polit- the less acculturated the immigrant the better ical histories of their native countries [43]. their mental health; this varies, however, by Evidence suggests that Latinos from Central Latino ethnic group and disorder [78]. To America predominantly migrate from war-torn formulate more accurate diagnoses and culturally countries, placing them at higher risk of develop- sensitive treatment plans, it is imperative that ing post-traumatic stress disorder (PTSD) [142, mental health professionals explore acculturative 143], while Latinos from other regions might, stress with their patients. It is also important to instead, may solely experience discrimination. In explore the patient’s age of migration, educational addition, although Puerto Ricans have US citi- attainment, and level of fluency in both Spanish zenship, many still experience prejudice from and English. Per Santiago-Rivera et al. [26] in a non-Latino Whites that fail to acknowledge their survey of Latinos conducted by The Washington citizenship [143]. As such, migration histories Post, the investigators found that “Latinos who and acculturation processes affect mental health retained dominant use of the Spanish language outcomes among Latinos [31] and thus warrant have a more traditional value structure than those attention from mental health providers. Latinos who are bilingual.” Language is, 11 Cultural Sensitivity: What Should We Understand About Latinos? 215

Table 11.1 Cultural differences between Anglo-Americans and Latinos Anglo-Americans Latinos (as) Individualistic perspective Collectivist perspective Nuclear family oriented Extended family oriented (protective factor) Individualism (autonomy independence) Familismo (family connectedness/interdependence) Support lifelong parent–child cohesion Egalitarian (horizontality) Hierarchy (verticality) Emphasizes personal authority Use of pronouns of respect such as usted, señora, señor, don, doña Autonomy from parental approval as Respect for parental authority persists throughout life, e.g., not hallmark of optimal adult development talking back Encourage to speak their own mind Spanking more acceptable form of discipline Less tolerance for spanking Emphasizes non-blood relationships Emphasizes blood relationships (mother–child) (wife–husband) Lifelong bond among siblings Confrontation and competition Affiliation and cooperation Need for more space More physical closeness Low context communication (relies primarily High context communication (relies more on nonverbal on the explicit verbal part of the message) communication) Direct communication Indirect communication (use of third persons, allusions, proverbs, metaphors, jokes, and stories to transmit information) Business like (task oriented) Personalismo (high level of emotional resonance and personal involvement with family encounters or friends) Emotive style, person oriented Patriarchal (machismo) Dignity of the individual: focuses on the Dignity of the individual: focuses on the inner qualities external qualities (values achievement) (experience self-worth regardless of worldly success or failure) Structure and task oriented Spontaneity in interpersonal relationships, serendipity, chance Predominantly protestants (use of priests, Predominantly Catholics (use of saints as intermediaries) ministers as intermediaries) Do not emphasize supernatural forces Importance on the spiritual domain (supernatural forces) Internal locus of control External locus of control (view by Anglos as fatalismo) Attribute the control of life events to luck, supernatural forces, acts of God, or other external forces Externalizing conversations: outer Externalization conversations: externalization (talking about problems as they Inner externalization (talking about a problem as it will be can be defeated/control) necessary to coexist with it) Encourages accepting or being resigned to problems therefore, an important factor to evaluate and to likelihood among Latino youth [148]. As such, it consider when working with this population. is clinically important to explore the “meaning” According to the “acculturation gap hypothesis,” each family member assigns to his/her experience immigrant children and their parents acculturate of identity and adaptation as differences between at different rates leading to acculturation gaps individuals can contribute to family dysfunction [147] that can cause family conflict and, in turn, [26, 31]. For example, a first-generation Latina have a negative impact on immigrant children. In mother who immigrated to the USA 15 years ago a study examining the link between parent–youth might have more difficulty adapting to American differential acculturation and likelihood of cultural demands as compared to her US-born substance use in Latino youth, acculturation gaps children. More specifically, if she is less proficient were associated with increase family discord and in English than her children, intergenerational less effective parenting practices, which, in turn, conflicts and power struggles might ensue. As were related to increase in future substance use such, identifying different levels of acculturation 216 A. L. Jiménez et al. among family members and their adaptation that familial attachments protected Puerto Ricans expectations in the USA might help a family living in Puerto Rico against antisocial and dis- reframe its problems, regain cohesiveness, and ruptive behavior disorders in children. Similarly, create a more constructive narrative. Wahl et al. [155] showed that greater positive family relations had a protective effect among Mexicans and Puerto Ricans, reducing the odds Familismo of alcohol use and binge drinking, but were in fact a risk factor for Cubans, increasing the odds As Santiago-Rivera et al. [26] note in their book of alcohol use and binge drinking. Per Santiago- on counseling, Latinos and La Familia, “family Rivera et al. [26] reliance on family and commu- is the heart and soul of Latino culture” (“la nity networks could serve to buffer the negative familia es el corazón y espíritu de la cultura consequences of discrimination in employment, Latina,” p. 19). Latinos are family oriented and education, and housing for Latinos. thus maintain family connections, or “familismo.” Adopting a collectivistic perspective might Latinos encourage interdependence, cohesive- be difficult for Anglo-Americans, who hold a ness, and cooperation among family members. worldview that emphasizes individualism, com- Latino families, for example, do not expect chil- petition, and independence [25]. Mental health dren over the age of 18 years to move out of their providers should be cautious not to impose this house, instead supporting lifelong parent–child perspective on Latinos as it might contribute to cohesion [31]. This connectedness and interde- poor treatment adherence and lower retention in pendency among Latinos are qualities that are care. For example, a therapist’s emphasis on a sometimes erroneously interpreted by Anglo- patient’s personal growth at the expense of fam- Americans as a sign of pathologic codependency ily well-being might propagate this individualis- [26, 143]. As Falicov [31] states, “the process of tic, independent perspective. More specifically, separation/individuation, so highly regarded in if a therapist were to encourage a young adult American culture, is deemphasized in favor of Latina to move out of her house, become more close family ties, independent of age, gender, or independent, and concentrate more on her indi- social class” (p. 175) among Latinos. They share vidual goals than those of her family, this could a collectivistic perspective that places greater unwittingly create an internal conflict within the value on familial needs over individual ones patient and lead to her prematurely terminating [149–151]. Family ties extend to aunts, uncles, care. A more culturally sensitive approach to cousins, grandparents, godparents, and even to this clinical situation would be to encourage the close friends. When considering who could be patient to explore how to accomplish her goals included in the patient’s treatment (family ther- in a manner consistent with her cultural and apy), careful consideration should be given to familial values, thereby preventing treatment extended family members. Members of the dropout. Helping patients develop solutions extended family, especially grandparents, play a consistent with their values may result in better central role in raising grandchildren and in medi- clinical outcomes. According to Bernal et al. ating conflict resolution [26, 150]. Maintaining [136] “interventions that take into consideration family ties and connections appears to be protec- the role of family, spirituality, language, and tive against psychiatric disorders in Latino adults acculturation are likely to augment engagement and adolescents. In fact, family disruption and and retention and to produce positive outcomes conflict are associated with an increased risk of (p. 323).” Hence, evidence suggests that because mood disorders among Puerto Ricans [152] and of “familismo” and maintaining a collectivistic SUDs among Mexican American adolescents perspective, Latinos are often more responsive [153]. In a population-based study of psychiatric to treatment approaches that incorporate family disorders in children, Bird et al. [154] concluded members, perspectives, or values [156]. 11 Cultural Sensitivity: What Should We Understand About Latinos? 217

Personalismo aware that they are a cultural expression of appreciation. For example, some counselors or therapists Personalismo refers to the value placed on building might feel uncomfortable if, at the end of a session, interpersonal relationships by Latinos. a patient approaches them with a goodbye kiss on Personalismo emphasizes warmth and friendliness the cheek or a touch on the shoulder as a demon- over formality and detachment and is characterized stration of gratitude. This could create an ethical by a high degree of emotional and personal involve- dilemma for therapists who fear that these actions ment between family members and friends [157]. risk breaking boundaries between the patient and Latino patients may express themselves in a highly therapist. In these instances, it is recommended that emotive manner during a mental health encounter, the therapist act prudently and evaluate his or her instead of adopting a task-oriented demeanor or own cultural belief system. Another related issue presenting as emotionally detached. Latinos value involves the giving of gifts on behalf of the patient. connectedness with their provider and may ask per- As a means of expressing appreciation, a Latino sonal questions of their provider. This behavior patient might choose to give a gift to his or her should not be interpreted as a possible boundary therapist. This, too, may represent an ethical violation; instead, it is a culturally accepted behav- dilemma for the therapist; hence, it is important ior that views self-disclosure as a means for foster- that the therapist be aware that it is a common prac- ing warmth within a relationship [26, 151]. Many tice among Latinos to offer gifts as a token of their scholars suggest that therapists engage in small appreciation. If the therapist were to reject a gift talk, or “pláticas,” that include judicious self-dis- from a Latino patient, the patient might interpret closure to promote personalismo and thus enhance the therapist’s action as rude or as a sign of rejec- the therapeutic relationship [25, 26]. tion [147]. Therefore, it is important that the thera- Another manifestation of personalismo is affec- pist assess the reasons why the patient could be tion [158]. The degree of physical proximity per- offering the gift. In general, patients’ gifts usually missible by Latinos is very different than that of represent a token of appreciation and are typically Anglo-Americans. Latinos tend to be more com- inexpensive, such as a souvenir or native food from fortable with closer physical proximity than that their country. If the gift offered is expensive, the typically accepted by Anglo-Americans. For exam- therapist should discuss the meaning of the gift ple, if a Latino patient were to place his or her chair with the patient before rejecting it. closer to his or her therapist during a psychotherapy session, this should not be interpreted as a boundary violation, but instead as a cultural expression to Respeto enhance comfort. Many Latino groups, particularly those from the Caribbean and the coastal areas of Another value that Latinos highly esteem is res- Latin America, tend to be more expressive and peto, or respect. For Latinos, being respectful and uninhibited in communication style [26]. They considerate toward others is very important. The value expressions of cariño, or terms of endear- value of respeto refers to the way one should treat ment, either verbally or nonverbally, as a mean to others and is a means of establishing boundaries foster the relationship. Some verbal expressions of and hierarchy [159]. Obedience and respect for cariño between family members and friends parental authority and family bond are values that include diminutive terms such as “mi amorcito” are highly stressed in traditional Latino families. (my little love), “negrita” (little Black woman), and Therefore, Latino adolescents often struggle with “negrito” (little Black man). Nonverbal demonstra- incongruence between social norms taught at tions of cariño include kissing on the cheek upon home, based on respect for authority and elders, greeting, touching the person while talking, and and American-based same age peers’ norms, cen- hugging. The patient may use expressions of cariño tered around individualism and independent during the therapeutic process; providers should be achievements. 218 A. L. Jiménez et al.

Latinos typically employ a hierarchical com- wide range of Christian denominations have munication style, while Anglo-Americans typi- proliferated, the predominant religion among cally employ a communication style that is more Latinos is Roman Catholicism [26]. While the egalitarian [25, 26]. The hierarchical communi- Pew Research Center’s 2013 National Survey of cation style used by Latinos is manifested and Latinos and Religion found that 55% of adult supported through language using specific pro- Latinos identify as Catholics, nearly one in four nouns. For example, authority figures, parents, Latino adults (24%) is now a former Catholic and elders are generally addressed with respect [160]. Comparing the 2013 survey results to data using the formal second person usted (you), gathered by the Pew Research Center in 2010, instead of the informal second person tú (you). there has been a decrease in terms of Latinos self- Titles of Don (for males) and Doña (for females) identifying as Catholics from 67% in 2010 to are used by both younger adults and children 55% in 2013 [160]. Some religious celebrations before an elder’s first name (i.e., Doña María) as include: Catholic bautismo (baptism) and “Dia a way of demonstrating respect [147]. Other for- de los Muertos” (Day of the Dead). The second is mal pronouns used are señor (Mr.) and señora a Mexican ceremony to remember loved ones (Mrs.). It is worth commenting on the fact that who have passed away. Other religious festivities Latinos from South American countries such as include first communions, marriages, funerals, Argentina, Uruguay, and Chile might not be com- and the Holy Week before Easter. Some Caribbean fortable with using more formal pronouns since Latino countries also practice Santería, a fusion they usually use “vos” (Argentina) or “tu” of Catholicism and African traditions. Latinos (Uruguay, Chile), instead of “usted.” Therefore, may seek help from traditional folk healers such providers must take a curious stance about a as santeros (Cuban), curanderos (witch doctors patient’s heritage and cultural background asking or brujos/Mexican), and espiritistas (Puerto patients directly about their preferences, instead Rican) to deal with health and mental health of making assumptions that can negatively problems [26, 161]. impact the therapeutic relationship. When com- It is common to see altars in Latino homes mencing therapy with a Latino patient, it is with statues of favorite saints, pictures of important that the therapist address the patient in deceased family members, and lit candles. If a more formal manner using the pronoun, “usted,” family member is sick or in trouble, Latinos pray, as a way of demonstrating respect until the patient seeking comfort and support in God. It is also expresses the preference that he or she be very common for Latinos to rely on a higher addressed more informally. It is also important to power (e.g., God) to create meaning out of note that some Latino ethnic groups, such as the various life experiences. This is particularly true Dominicans, do not look directly at their thera- when trying to achieve goals in life [26, 148]. For pist when in treatment because it connotes a lack example, the expression “si Dios quiere” (if it is of respect toward authority figures. This nonver- God’s will) exemplifies this. In addition, when bal communication is an example of the cultural things do not have the outcome expected or when value placed on respect. Providers should not tragedies occur, a Latino might say: “Dios sabe lo label this behavior as denoting low self-esteem; que hace” (God knows what he does) or “no hay instead, it should be interpreted as a cultural mal que por bien no venga” (referring to some demonstration of respect for authority. good may come out of bad things) or “no era de Dios” or “Dios no quiso que fuera” (it was not God’s will, God did not want it to be). This Spirituality emphasis on spirituality has been misinterpreted by many Anglo-Americans as “fatalismo” or as Spirituality is a critical value among Latinos. Latinos having a more fatalistic perspective of Religion and spirituality play an important role in life. Anglo-Americans might interpret the the everyday life of Latinos [26, 148]. Although a reliance on a higher power as a sign of resignation. 11 Cultural Sensitivity: What Should We Understand About Latinos? 219

For example, Anglo-Americans typically ness), especially if it expresses a negative emo- emphasize that one rely on the internal qualities tional state, is rude or insensitive. As such, Latinos of will power or perseverance, while Latinos rely rely more heavily on indirect communication to on a higher power to help them confront painful denote conflict or differences [31]. circumstances in life [26, 162]. Of note, this does Addressing patients appropriately can be chal- not mean that Latinos do not acknowledge their lenging for some providers further exacerbating internal strengths, but instead believe that a cultural distance between the provider and spiritual dimension is crucial to making meaning patient. For example, it is quite common for out of life. Latinos to have combined names and last names The emphasis on spirituality and religiosity which can be confusing for US practitioners who among Latinos appears to be related to nativity are used to one name and surname. Many Latinas and acculturation. In the Pew Research Center’s have combined first names such as “María Luisa,” 2013 National Survey of Latinos and Religion “María José,” and “Ana María,” but are often [160], religion was reported to be more important addressed by providers as simply “María,” lead- to immigrants than to US-born Latinos. ing to the possibility of tension between the Approximately 69% of foreign-born Latinos as patient and provider and even be taken by the compared to 51% of US-born Latinos endorsed patient as culturally insensitive. The same prob- religion as being “very important.” The same lem can apply to Latinos who have combined survey found that six in ten foreign-born Latinos names like “José Ignacio” or “Juan Francisco”; if are Catholic, compared with about half of the the patient goes by their first name only omitting US-born Latinos (48%). Therefore, clinicians the second name, it can be taken as offensive and should be aware of these differences in practice lead to confusion since some patients might not and acculturation and explore the religious respond to providers calling them only “María” preference and practice of each individual patient or “Juan” if their name is, for example, “María in a respectful way. Inés” or “Juan Carlos.” Double or hyphenated Latino surnames may also seem complicated, with the father’s name preceding the mother’s Communication Patterns last name, but Latinos usually appreciate when they are called by both names and/or both last Latinos generally rely on high context communi- names. Not addressing patients by their given/ cation as compared to Anglo-Americans [31]. preferred name or surname can be considered a High context communication is characterized by microaggression that can jeopardize the thera- the predominant use of nonverbal communica- peutic relationship. When in doubt, the best tion; low context communication relies more approach is to ask the patient how he or she heavily on explicit verbal messages [31]. Low would like to be addressed. context communication is associated with com- Positive emotional expressiveness among municating in an indirect manner, using jokes, Latinos is characterized by warmth, physical sarcasm, diminutives, allusions, proverbs, meta- closeness, gesticulations while talking, and the phors, parables, and the use of the third person. use of terms of endearment to compliment friends For example, during a couple’s therapy session, a and family members. Many Latinos are also wife might tell her husband, “palo que nace thought to speak in a louder voice when emoting. doblao, jamás supo que enderezca” (“a tree that Due to the high level of indirect communica- has grown bent cannot be straightened”), refer- tion used by Latinos, therapists should use meta- ring to her perception that he will never change. phors as a technique in engaging this population. Also, a Latino might say “one could be angry Narrative therapy uses stories and metaphors to at…,” instead of more directly stating, “I am break down destructive cultural assumptions and angry at you.” This is because some Latinos construct new and more positive views. For believe that direct communication (i.e., assertive- example, Garcia-Preto [163] uses the metaphor 220 A. L. Jiménez et al. of a bridge to help Latina patients deal with the nificant jobs or trafficking drugs. The people he dilemma of living between two cultures. As cares for are in gangs and sell drugs, and the peo- Garcia-Prieto [163] relates: ple that oppress him are ones that perceive him as lazy, dumb, and a loser, getting him into a double I am able to share the metaphor of the bridge as a safe place to understand the world in which they bind (no win situation). He is frustrated and loses [Latinos] grew up and the possibilities of the new his temper easily, which leads to him getting into world they have entered. When I help people fights with others in the neighborhood and mostly construct the bridges they need for this journey with individuals that are non-Latino Whites. A between cultures, my own bridge becomes sturdier and wider (p. 273). narrative therapist should explore his family migration story, his level of acculturation, his Many Latinos live between two cultures, that of preferred language for treatment, his construc- their country of origin and that of their host coun- tion of self, his individual strengths, and instances try. The acknowledgment that cultures are not of positive outcomes, including times when he static, but are instead in constant flux, helps one resisted being aggressive or behaved in a way understand the identity development of Latinos that contradicted the story he tells himself about living in the USA from a social constructionist his identity. This adolescent’s self-identity as a perspective (narrative perspective) [163, 164]. failure should be analyzed in terms of negative A narrative framework works well when internalized cultural narratives that emphasize applied to a minority or multicultural framework oppression. To deconstruct these assumptions, because it emphasizes a view that is contextually the therapist could ask the adolescent how he historical and political. As mentioned previously, came to believe that Latino men could never be the focus of narrative therapy is to deconstruct intelligent or successful in the USA. established truths that oppress a group of people. The narrative therapist might also use the How Latinos as a group are perceived and the technique of externalizing the problem by telling negative connotations given by the dominant cul- the adolescent: “When you feel overtaken by bad ture may lead to the development of a problem- temper [emphasizing that the bad temper, not atic identity narrative that contributes to the cycle adolescent, is the problem], what does it make of oppression and discrimination. Negative per- you do?” This technique separates the problem sonal narratives, however, can be broken down from the person, thereby helping the adolescent and reconstructed. The narrative model empha- develop a more positive view of himself. The sizes the strengths of a given individual; when therapist should also explore unique outcomes problems are identified by the therapist, they are (behaviors that are exceptions to the negative then externalized to help patients realize the toxic dominant story) that can help him create a more effects cultural narratives have on their negative positive story of himself. For example, the thera- identity narrative. pist might explore and highlight occasions during For example, an adolescent Latino who drops which the adolescent was respectful toward oth- out of school to help sustain his family finan- ers, considerate, peaceful, and successful in cially may have internalized a negative cultural school, as a way of constructing an alternative dominant narrative of prejudice. This narrative, story of success and possibility. The therapist in turn, leads him to believe that he may never could also include dichos (proverbs) or meta- reach his professional goals in society since most phors to help the patient develop a more positive Latinos are “failures” or have difficulty accom- self-image. An example of a treatment that uses plishing their goals. He might even believe that narratives is Cuento therapy, which has been because he is not fluent in English, he is not intel- shown to be effective in treating symptoms of ligent and will never attain a university educa- anxiety and post-disaster trauma among Puerto tion. His self-constructed story might be that just Rican children and adolescents in New York City. because he is mestizo, he will never succeed in Cuento therapy is a form of child psychotherapy the USA, which could lead to his holding insig- in which Puerto Rican mothers recount folktales 11 Cultural Sensitivity: What Should We Understand About Latinos? 221 from Puerto Rican culture to their children (refer Whites to remain in treatment [22]. There are to Costantino et al. [165, 166] for more details). also significant differences in the prevalence of A narrative therapist assumes a stance of being mental health disorders and SUDs as compared “humble” and respectful, emphasizing a collab- to non-Latino Whites [21, 43]. orative perspective between the therapist and A growing demand for care coupled with high patient, instead of an “expert” stance. This shift unmet need represents a significant challenge to toward a more collaborative stance fosters Latinos as they confront extensive service dispari- patients’ empowerment, making this model suit- ties [7, 8]. To increase Latinos’ adherence to treatable for working with disenfranchised popula- ment, it is important that mental health providers tions. Acculturative stress and problem definition understand and be sensitive to the cultural nuances are constructions that are in constant flux; as of this population. For example, cultural values of such, identity construction is constantly chang- familismo, personalismo, respeto, and spirituality ing. Using a perspective that values change takes are highly important to Latinos. Therefore, in the the environment (context) into account, and the collective experience of the authors, we recom- family and political challenges that affect people mend family therapy as the preferred treatment under consideration are critical to working effi- choice for Latinos or shifting from an individualis- ciently with a minority population. tic perspective to a more collective one when treat- Other culture-centered family therapy models ing Latinos. This could represent a challenge for that have been effective with Latinos include the mental health providers that hold an individualistic Bicultural Effectiveness Training model (refer to perspective. It is equally important that mental Szapocznik et al. [167] for more details), the health providers be cognizant of the fact that Multidimensional Ecosystemic Comparative Latinos hold a more hierarchical communication Approach (refer to Falicov [31] for more details), style that is conveyed using language that implies and Bowenian models (refer to Inclan and respect. Latinos also typically use more nonverbal Hernandez [168] for more details). Santiago- communication, including body language, hand Rivera et al. [26] also suggest the use of culture- movements, and tone of voice, to express them- centered genograms as a systemic and ecological selves. In addition, Latinos use more covert meth- assessment tool. Using genograms, a technique ods of communication such as metaphors, stories, used in family therapy to collect information and dichos (proverbs) or indirectas (indirects) to about three generations, the therapist can encour- convey meaning. Therefore, it is recommended age the development of new narratives in a non- that Spanish providers be used during therapy as a threatening way and better understand the technique to enhance the therapeutic alliance. In migration history, family struggles, and coping addition, due to the heterogeneity encountered in patterns that exist in Latino families [26]. For the Latino population, mental healthcare providers other evidence-based culturally adapted treat- should familiarize themselves with the historical, ments for Latinos, refer to Bernal et al. [136] and cultural, and political experiences of prejudice, Bernal and Domenech-Rodriguez [169]. discrimination, and sense of disenfranchisement experienced by Latinos living in the USA [156]. Even though inconsistent findings have been Conclusion found with ethnic matching, it would be optimal that therapists who work with Latinos be bilingual, Latinos are the fastest-growing minority group in culturally sensitive, and cognizant of their own the USA. Because their growing demand far biases and perspectives when working with this exceeds the service capacity able to address their population. We also recommend using a narrative needs, Latinos suffer marked disparities in perspective that emphasizes the use of positive sto- education, mental health, and healthcare ries instead of ones that emphasize prejudice, utilization as compared to non-Latino Whites. In oppression, and disenfranchisement. Helping addition, they are less likely than non-Latino Latino patients living in the USA construct more 222 A. L. Jiménez et al. positive stories of themselves will serve to depression in the United States. 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Jeremy A. Wernick, Samantha M. Busa, Aron Janssen, and Karen Ron-Li Liaw

Introduction school-age childrens’ insight into the limits placed on them based on their gender to the The Continuum Approach: Battle Cry stigma associated with paid paternity leave, the for a New Generation Special Issue illustrates how our social attitudes of Clinician-Activists toward gender and sexuality have a meaningful impact across generations and cultures. We chose the title of this chapter with clear intent. Rethinking gender in a rapidly evolving social How many LGB, LGBT, and LGBTQ scholarly climate driven by social media and increased vis- works have you read in the pursuit of understand- ibility for gender and sexual minorities requires ing of how gender and sexuality develop through shifts to our knowledge base as providers. The the lifecycle, affect physical and mental health “Discussion Guide for Teachers and Parents,” and well-being, and impact social discourse, pol- provided by the Special Issue, opens with a icy, and law? In January 2017, the National “primer” of relevant definitions and helpful ques- Geographic published a Special Issue entitled, tions to clarify how complex the development of “Gender Revolution,” highlighting how resilient gender and sexual identity is universally [1, 2]. It our younger generations are in moving beyond is no surprise that readers are encouraged to con- traditional, dichotomous categories and living sider how culture, language, region, biology, and life on the gender and sexual continuum. numerous other factors contribute to the many The topics covered in the Special Issue reflect self-defining labels created by young people to just how far ahead youth raised during this “gen- capture the vast range of sexual and gender der revolution” are in understanding and living expression and identification. on the spectrums of gender and sexuality. From We wrote this chapter with “all of the above” in mind and hope that you find the following principles and pearls, in some way, applicable to every patient encounter, team meeting, research J. A. Wernick (*) · S. M. Busa · K. R.-L. Liaw protocol, and your own evolving perspectives. Department of Child and Adolescent Psychiatry, The chapter begins with an introduction to seven NYU Child Study Center, New York, NY, USA e-mail: [email protected] guiding principles for working with people on the sexual and gender continuums, followed by a A. Janssen Pritzker Department of Psychiatry and Behavioral brief review of key historical periods within our Health, Ann and Robert H. Lurie Children’s Hospital field and DSM-5 changes. The chapter explores of Chicago, Chicago, IL, USA developmental considerations, assessment within

© Springer Nature Switzerland AG 2019 229 R. Parekh, N.-H. T. Trinh (eds.), The Massachusetts General Hospital Textbook on Diversity and Cultural Sensitivity in Mental Health, Current Clinical Psychiatry, https://doi.org/10.1007/978-3-030-20174-6_12 230 J. A. Wernick et al. a biopsychosociocultural framework, comorbid A man, who is attracted to and has sex with medical and mental health concerns, the impact both women and men, may identify as of minority stress, and considerations for those heterosexual. A woman, who is attracted to both who are multiple minorities. Finally, we offer men and women and is married to a woman, may clinical pearls to consider in treatment and special identify as lesbian in her twenties but make a considerations for gender variance. conscious decision not to label herself during the rest of her adulthood.

Seven Guiding Principles 5. Gender may develop based upon biologic sex, but this is not always the case (i.e., transgender, 1. Gender and sexuality exist in continuums with intersex, androgynous individuals). Gender infinite possibilities, not in discrete, mutually can be broken down into gender identity, exclusive categories, such as male vs. female roles, and presentation as well as other realms vs. transgender and heterosexual/straight vs. of gender expression both within and outside homosexual/gay/lesbian vs. bisexual vs. of the context of culturally defined norms. asexual. 6. There are biological, psychological, social, 2. The gender and sexuality continuums are sep- and cultural influences at play in gender and arate, yet interrelated realms. For example, sexual developmental trajectories. The consider a trans-man (female to male strength and salience of these influences transgender person) who is married to a fluctuates as one moves through the lifecycle. woman and self-identifies as heterosexual. For example, biological influences such as The basic concept of sexual orientation relies, genetic factors and hormonal influences play a by definition, on gender considerations. This strong role during prenatal and pubertal devel- individual may have identified as lesbian in opment. Social factors, such as family and adolescence and following his gender peer relationships, robustly shape behavior reassignment now identifies as straight. during the preschool and school-age years. 3. The gender continuum breaks down into sepa- 7. Each individual is unique and composed of rate, but not mutually exclusive, masculine multiple identities that exist within and inter- and feminine continuums. Each individual, act with other sociocultural realms, such as regardless of biologic sex, may embody a socioeconomic status, geographic region, race combination of male- and female-stereotyped and ethnicity, religious and spiritual affiliation, traits, behaviors, roles, and identifications. and gender and sexuality, among others. For example, a biologic male, who is a husband and a father, may play a more nurturing, Figure 12.1 offers a simple visual scale to emotionally expressive role within a family, use in clinical encounters. Across the top of the while his biologic male partner may play a figure, there are two continuums, male/mascu- more assertive, analytic role. Consider the line and female/feminine, with intensity scales balance of masculine- and feminine-ranging from 0 to 10. Below, there are four stereotyped traits embodied by a lesbian, realms of assessment—gender identification, scientist mother, who leads a research program gender role and expression, sexual attraction, but has chosen a flexible work schedule, so and sexual behavior—to inquire about during that she can be home for school pickup and the course of your work with each client. Each family activities. of these realms will be explained further in sub- 4. Sexuality is composed of three distinct realms: sequent sections. The integration of these four orientation and attraction, behavior, and realms makes up one’s consolidated sexual and identity. These three realms are interrelated gender identity. but not always aligned. Throughout the chapter, we will be utilizing the cases of BA and SL to illustrate key concepts 12 Not by Convention: Working with People on the Sexual and Gender Continuum 231

Male/masculine 01 2345678910

Female/feminine 0 1 2345678910

Four realms of assessment

Gender • Male identification • Female

Gender role • Male Consolidated & expression • Female sexual & gender identity

Sexual • Male attraction • Female

Sexual • Male behavior • Female

Fig. 12.1 Gender and sexuality assessment tool and provide recommendations for assessment Historical Context and treatment. BA, a 13-year-old assigned female at birth, pres- The field of medicine has a checkered and storied ents for an initial psychiatric assessment after past when it comes to understanding sexual orien- increased anxiety and panic attacks in the context tation and gender identity. As far back as the late of anticipating the start of a new high school. Three 1800s, physicians such as Magnus Hirschfeld months into treatment, BA reports that while they are uncomfortable attending a new school, they began to conceptualize sexual orientation and gen- also are intensely uncomfortable in their body, der identity as biological variance rather than as expressing that they identify as agender. criminal. Meanwhile, contemporaries such as Karl SL, a 17-year-old assigned female at birth, pres- Westphal argued that homosexuality was an illness ents for an initial psychiatric assessment after that should be treated [3]. Physicians and psychol- recently disclosing to his mother and father that he ogists argued among each other and the prevailing prefers male pronouns, would like to start using a theories began to evolve and change over time. gender-neutral name, and is interested in starting hormone therapy to present as more masculine in Freud brought attention to psychosexual function- college. SL meets weekly with a psychologist to ing and to the concepts of sexual orientation and address symptoms of social anxiety and depres- gender identity. His ideas about sexual orientation sion, as well as intermittent non-suicidal self-inju- and gender identity changed over time and had a rious behaviors (NSSIBs). SL and his parents expressed concern about his current therapist’s profound impact on theories to come. In answer- lack of sensitivity to the possible impact of Gender ing a letter written by a mother hoping for Freud to Dysphoria on his current mental health challenges. cure her son of homosexuality, he wrote: 232 J. A. Wernick et al.

Homosexuality is assuredly no advantage, but it is revised to remove homosexuality and replace it nothing to be ashamed of, no vice, no degradation; it with sexual orientation disturbance. However, it cannot be classified as an illness; we consider it to be a variation of the sexual function, produced by a is not until 1987 that it is removed completely. certain arrest of sexual development. Many highly Meanwhile, variation in one’s gender identity is respectable individuals of ancient and modern times similarly considered pathology and is currently have been homosexuals, several of the greatest men classified under the diagnosis of gender identity among them (Plato, Michelangelo, Leonardo da Vinci, etc.)… By asking me if I can help, you mean, disorder. I suppose, if I can abolish homosexuality and make normal heterosexuality take its place. The answer is, in a general way, we cannot promise to achieve it. In a certain number of cases we succeed in developing DSM-5 Changes the blighted germs of heterosexual tendencies which are present in every homosexual, in the majority of Similarly to how visibility of lesbian, gay, and cases it is no more possible. [4] bisexual people helped to change the medical culture’s views of sexual orientation, the The disagreement within the psychiatric com- increasing visibility of transgender and gender- munity about homosexuality was not a surprise, variant individuals continues to move the field nor was it surprising that the prevailing views away from pathologizing identities. As a result, perceived both variations in sexual orientation significant changes were made to DSM-5 in and gender identity as illness. The concept of 2013, and gender identity disorder was removed identity as pathology persisted, and by the time and replaced with gender dysphoria. In order to the first edition of the DSM was released, homo- avoid stigma and create a more appropriate sexuality was classified as a sociopathic person- diagnostic label, the change to “gender dysphoria” ality disturbance (Table 12.1). The time from the highlights the distress that often but does not 1940s, after the release of the DSM to the 1970s, always come with variability in gender identity. with the revision of the DSM-II, was an era of Gender dysphoria is described as “a marked great social and academic change. Alfred Kinsey incongruence between one’s experienced/ brings light to the notion of sexuality as a con- expressed gender and assigned gender, of at least tinuum and exposes a much higher prevalence of six months duration…” [9] and requires clini- homosexual behaviors than was thought [5]. cally significant distress or impairment. As such, Evelyn Hooker publishes “The adjustment of the while many gender-variant individuals go male overt homosexual” and with her elegantly through a period of dysphoria as a part of devel- designed study challenges the notion that gay opment, it is this dysphoria rather than the devel- men have more psychopathology than heterosex- opment itself that is pathologized. The topic of ual men [6]. Gay men and lesbians begin to orga- gender variance in childhood continues to be nize and advocate for their rights, and the 1969 quite controversial and is reflected in the stricter Stonewall riots bring momentum and publicity to diagnostic criteria for this diagnosis in children the gay rights movement. Concurrently, Bieber than in adults (six positive criteria are required and Soccarides set forth the theory of causality of for children as opposed to two for adults). homosexuality as a domineering mother and While changes to DSM-5 attempted to reduce absent father (Bieber) or as a result of incapaci- the stigmatization of gender diverse individuals tating childhood trauma [7, 8]. They argue for and allow for consistent recognition of these therapeutic cures for homosexuality, the tech- identities in healthcare settings, capturing the niques of which formed the basis for what is now complexity and variability of gender and sexuality referred to as reparative therapy. Gay men and identity remains a challenge. Despite ongoing lesbians began to picket the American Psychiatric controversy and disagreement about the change Association Conferences and argue fiercely that to gender dysphoria, there is a clear progress in they are not psychiatrically ill by nature of their the 60 years since the DSM classified LGBTQ sexual orientation. By 1973, the DSM-II is individuals as sociopathic. By examining our 12 Not by Convention: Working with People on the Sexual and Gender Continuum 233 DSM-5— 2013 N/A Gender dysphoria DSM-IV—1994 N/A Gender identity disorder DSM-IIIR—1987 Removed from the Removed DSM Transsexuality Transsexuality (adults); GID-NOS (children) DSM-III—1980 Ego-dystonic homosexuality Transsexuality (adults); Transsexuality atypical GID (children) DSM-IIR—1973 Sexual Sexual orientation disturbance Sexual Sexual deviation DSM-II—1968 Sexual deviation: deviation: Sexual homosexuality Sexual deviation Sexual DSM-I—1952 Sociopathic personality disturbance along with deviation sexual psychopathy: N/A Sexual orientation and gender identity in the DSM Sexual Sexual Sexual orientation Gender identity Table 12.1 Table 234 J. A. Wernick et al. field’s interface with sexual orientation and meaning and salience of one’s maleness or gender identity, we can begin to understand a femaleness transform throughout the preschool provider’s role in both the potential of creating years, latency, adolescence, and young adulthood, and/or eradicating stigma and bias and work as well as in the context of intimate relationships, toward a more open understanding of people on committed unions, parenthood, and later life. the sexual and gender continuum. One’s gender role, or one’s outward presentation and behavior, is often categorized as either typically male or typically female and also Developmental Considerations continues to change through the lifecycle. Family, and Basic Definitions peer, and prevailing societal norms and expectations all play a powerful role in shaping As mental health professionals, we are trained to outward manifestations of gender as well as think in a way that incorporates the various internal conceptions of the self [3, 11]. influences on a person’s life. Biologic and Biological contributions to gender develop- maturational processes, psychological factors, ment include genetic factors and hormonal influ- and social and cultural influences all play an ences. Money and Ehrardt’s biosocial theory important role in the development of gender and describes how genes and hormones influence sexuality through the lifecycle. Developmental children’s physical development, including their trajectories for gender and sexual minorities genitalia and secondary sex characteristics, likely share more similarities with the general which then in turn influences how they perceive population than differences. However, those themselves and how others perceive them [12]. areas of difference are also important to highlight Biology also influences gender role development given their potential impact on the therapeutic as children typically present with play that often alliance, reluctance or willingness to seek falls more typically in one gender or another. treatment, and physical and mental health Boys tend to prefer more rough and tumble play, outcomes. In this section, we will cover and girls more imaginative and social/relational fundamental concepts and stages of life, which play [13, 14]. By no means is this a hard and fast play a pivotal role in gender and sexual rule, as many of us recall or were “tomboys” or development. “girly boys” growing up, and these early tendencies and preferences do not necessarily dictate future adult gender identity and roles. Gender Development The biosocial theory describes a number of critical biological and social episodes or events, By the age of 2 or 3 years old, most children have such as inheriting either an X or Y chromosome developed a sense of basic gender identity and from one’s father at the time of conception, the have labeled themselves as boys or girls. formation of female or male differentiated gonads Somewhat later, these children develop gender (ovaries or testes) by week 8 of gestation, and the stability, meaning that they perceive their gender subsequent secretion or non-secretion of prenatal as being stable over time. That is, they predict sex hormones, which impact sex differentiation that boys grow up to be men, and girls grow up to and gender development. Prior to week 6 or so of be women. By age 5–7, children typically develop development, male (XY) and female (XX) an understanding of gender consistency, which embryos are the same except at the genetic level. allows them to realize that one’s gender is also Both have the capacity to form either male or stable across situations [10]. Though basic gen- female reproductive systems. Around week 8 of der identity develops during toddlerhood, a embryonic development, the secretion of deeper understanding of gender identity, one’s testosterone and Mullerian inhibiting substance awareness of one’s gender and its implications, (MIS) by the testes of a male embryo stimulates continues to evolve throughout the lifecycle. The the development of the male reproductive system 12 Not by Convention: Working with People on the Sexual and Gender Continuum 235 and, simultaneously, inhibits the development of even more receptive to spatial activities and the female reproductive system. In the case of a acquiring spatial skill. In contrast, girls may female embryo, the absence of testosterone and develop a richer array of neural pathways in areas MIS leads to the development of the female of the brain’s left cerebral hemisphere serving reproductive system, which is the default state in verbal functions, thereby becoming even more nature. Around 3–4 months after conception in a receptive to verbal activities and acquiring verbal male embryo, the ongoing secretion of skills [12]. testosterone leads to the growth of a penis and According to the social learning theory, chil- scrotum. In a female embryo, the uterus, cervix, dren acquire their gender identities and gender and vagina develop in a programmed fashion role preferences through differential reinforce- without hormonal control. ment and observational learning. Through differ- Hormones play a particularly prominent role ential reinforcement, children are encouraged or in gender development during the prenatal and rewarded, implicitly or explicitly, for gender- pubertal periods. During these sensitive periods appropriate behavior and discouraged or punished of development, exposure to androgens (male for gender-atypical behavior. Through observa- hormones) or estrogens (female hormones) may tional learning, children adopt the attitudes and differentially influence one’s physiology,behaviors of a variety of same-sex models [10]. chemical processes, and morphology and Numerous studies have shown that even before determine the body habitus, secondary sex the age of 2 and before children have acquired characteristics, and, to some extent, brain their basic gender identities, parents are already organization and lateralization of cognitive and differentially reinforcing their children’s interests language functioning [15]. The combination of and behaviors by rewarding those that are gender- biologic and social forces, ultimately, impact appropriate, such as praising a boy who is playing gender-related behaviors, roles, and identity. with trucks and blocks, and discouraging those Much of what we have learned in this field comes that are gender-atypical, such as admonishing him from work with patients who have genetic and when playing with dolls or dressing up [12]. hormonal syndromes, such as Klinefelter Social and cultural factors begin to influence syndrome (47 XXY), androgen insensitivity, and the complex and lifelong process of gender congenital adrenal hyperplasia, among others. development even prior to birth. What color will Within psychology, many theories have been the baby’s room be painted? What name have the proposed to explain the process of gender parents chosen? Why does the infant clothing development and differentiation. Given the scope color palette shrink to pink and blue? Without of this chapter, we will highlight a few key gender-specific colors, clothing, hairstyles, and conceptual trends. Halpern’s model offered a names, we would be hard-pressed to distinguish perspective on how nature and nurture might between baby boys and girls through their first jointly influence the development of many year or two of life (and arguably up until puberty). gender-typed attributes, such as spatial skills in The socialization process continues with parents males and language abilities in females. Halpern tossing their baby boys into the air and cuddling asserted that specific early experiences affect the their baby girls on their laps. Early in life, parents organization of the brain, which in turn influences and caregivers certainly provide the strongest one’s responsiveness to similar experiences in the social influence on gender development, but future. For example, due to social conventions during the preschool years and beyond, peers and and gender norms, boys who receive more siblings begin to exert a more significant opportunities to engage in spatial reasoning and influence. Popular culture and media also play explore a wider variety of spatial experiences powerful roles in shaping our ideas about gender may develop a rich array of neural pathways in roles and expectations, limitations and possibili- the brain’s right cerebral hemisphere that serve ties, and models for identification. spatial functions, which in turn may make them 236 J. A. Wernick et al.

There are vast differences across cultures in shape the ethnomusical experiences in this soci- what people expect of boys and girls. In Tahiti, ety [21]. Male musicians may perform for the few distinctions are made among males and public accompanied by instruments, whereas females; even the national language lacks gender women are typically restricted to private domains pronouns, and most names are used for both boys with female audiences. Talava, a specific type of and girls. Anthropologist Margaret Mead found Gypsy music that originated in the female varying patterns of masculine and feminine traits domain, is performed in public by homosexual in the members of three different “primitive soci- men who dress and behave like women. Based on eties” living in New Guinea. According to Mead’s their unique behaviors and established social observations, the Arapesh and Mundugumor both standing, one can argue that these individuals made limited distinctions between males and inhabit a third gender space within the local cul- females; however, gender expectations varied ture [21]. enormously between the two. The Arapesh ideal- ized stereotypically feminine traits, such as cooperation, sensitivity, and submissiveness. On the Sexual Development other hand, Mundugumor men and women revered aggression, violence, and stoicism, which Empirical research reveals that human beings are are typically regarded as masculine traits. Finally, sexual beings throughout the lifecycle with in the third society Mead observed, the sexuality manifesting itself in diverse and Tchambuli, women were expected to be domi- complex ways at different points in time. nant and exhibit a limited amount of emotion and DeLamater and Friedrich assert that the capacity men were regarded as more dependent, emo- for a “sexual response,” as manifested by erection tional, and irresponsible. Mead points out that the and vaginal lubrication, is present from birth. Tchambuli’s gender expectations are the opposite These physiologic responses as well as infant of those found in Western cultures [12, 16]. exploratory touching of their genitals can be seen In the Native American/First Nation culture, within the first 2 years of life. Around age 2.5–3 individuals may identify as being two-spirits, and sometimes earlier, the rhythmic manipulation which refers to people who are either biologically associated with adult masturbation can appear male and fulfilling the social role of a woman or and is a natural form of sexual expression. biologically female and fulfilling the social roles Between the ages of 3 and 7, there is marked of a man. Native Americans dissociate physical increase in sexual curiosity and exploration, such or biological traits from gender within the two- as “playing house” and “playing doctor” with spirit identity and, instead, emphasize the role of similar-aged peers. Through the elementary spirituality in creating gender. Two-spirits are school years, ages 6–9, sexual play becomes considered as having embodied both male and increasingly covert as children become aware of female spirits [17–19]. In some Native American cultural norms. communities, these two-spirits are revered and During preadolescence, ages 8–12, children celebrated for their superior spiritual status and tend to socialize and learn about sexuality with ability to see through both the male and female same gender peers. This social organization perspective. That being said, this celebration is changes dramatically during adolescence as teens not always the case [18, 20]. Regardless, the two- progress through puberty. During puberty, there spirit identity exemplifies the ways different is sudden enlargement and maturation of the social and cultural forces like spirituality can gonads and genitalia, development of secondary shape gender expression and identity. sex characteristics, and surge in sexual interest In Kosovo, homosexual Gypsy musicians use due to increases in testosterone levels and a music to negotiate the arbitrary boundary growing capacity for adult sexual interactions. between male and female genders. Cultural The process of achieving sexual maturity forces like religion and socioeconomic conditions continues through adulthood through committed 12 Not by Convention: Working with People on the Sexual and Gender Continuum 237 and/or noncommitted intimate relationships. invisible. Many theorists, including Erik Erikson, Later in life, women may undergo physical and Sigmund Freud, and Vivienne Cass, have written emotional changes associated with menopause as extensively on the topic of sexual identity and men progress through andropause. These proposed an array of stage models [24]. changes, however, do not preclude older people’s Within Erikson’s psychosocial theory of ability to engage in satisfying sexual activity in development, the stages of adolescence and all forms [22]. young adulthood bring important challenges in Sexuality can be broken down into three developing a core sense of personal and social domains: sexual attraction and orientation, sexual identity and achieving intimacy or “genuine behavior, and sexual identity. Sexual orientation mutuality and love” [25]. According to Cass refers to the predominance of erotic thoughts, (1979), who set the standard for homosexual feelings, and fantasies one has for members of a identity development, sexual identity is a particular sex. This also includes the intensity of universal developmental process that unfolds in a one’s sexual attraction toward members of the predetermined sequence through six stages: same or opposite gender and with whom one identity confusion, identity comparison, identity tends to fall in love. Sexual orientation may be tolerance, identity acceptance, identity pride, and fixed at birth or an early age and is considered to identity synthesis [26]. Though stage models be “immutable, stable, and resistant to conscious allow us to better conceptualize and categorize control” [23]. Based on our current body of human experience, there have been a number of research, the origins of sexual orientation are critiques with regard to their universality, appli- likely multifactorial and require further cability, accuracy, and ability to capture the investigation. unique features and range of diversity found Sexual behavior refers to the sexual activities within real-life experience [24]. in which an individual engages. What constitutes In light of these critiques, Savin-Williams [24] “sex” depends on whom you ask. Traditional proposed utilizing a “differential developmental definitions of “sex = intercourse” do not hold true trajectories” framework to better reflect the for many groups, such as teenagers, women, and diverse, unpredictable, and ever-changing lives men who have sex with men (MSM), among oth- of contemporary, same-sex attracted teens. ers [24]. Does only penile-vaginal intercourse Within this framework, Savin-Williams lays out count as “sex”? What about oral and anal sex, four basic tenets: mutual masturbation, and use of sex toys? Are these considered “sex” as well? When working 1. Similarities: Same-sex attracted teenagers are from a continuum approach, we should be as similar to all other adolescents in their specific as possible when inquiring about our developmental trajectories. All are subject to patient’s sexual orientation and behaviors while the same biological, psychological, and social taking an open, nonjudgmental stance, so that influences. He warns against exclusively every patient feels comfortable answering us focusing on sexuality as it runs the danger of honestly. misattributing normal adolescent experiences Sexual identity, or how a person labels their to sexual orientation. sexuality, represents an amalgam of one’s sexual 2. Differences: Same-sex attracted teenagers are feelings, fantasies, attractions, behaviors, and dissimilar from heterosexual adolescents in romantic relationships. Sexual identity is one of their developmental trajectories. Perhaps due the many dimensions of an individual’s identity, to unique, biologically mediated constitution or sense of self—who one is and how one fits into and cultural heterocentrism (negativity toward society. In contrast to more visible realms of iden- sex-atypical behavior, temperament, and tity, such as age, gender, race, and ethnicity, sex- interests), same-sex attracted young people’s ual identity, like spiritual and religious affiliation, psychological development is different from socioeconomic status, and occupation, is largely that of heterosexuals. 238 J. A. Wernick et al.

3. Heterogeneity: Same-sex attracted teenagers will no longer identify with the gender of the vary among themselves in their developmental opposite sex of which they were born. trajectories, and this can be similar to the Interestingly, a majority of these children with ways in which heterosexual teens vary among gender identity disorder (as defined by the themselves. The interaction of sexuality with DSM-IV) will later in life identify as being gay, gender, ethnicity, geography, socioeconomic lesbian, or bisexual [27, 28]. status, and cohort results in distinctive Another unique aspect of the developmental trajectories among teens. trajectory for sexual minorities is the process of 4. Uniqueness: The developmental trajectory of coming out. Coming out involves becoming a given person is similar to that of no other aware of and acknowledging one’s own sexual person who has ever lived. Given the profound identity (coming out to oneself) and disclosing diversity inherent in individual lives, general that identity to others (coming out to others). It is descriptions of group-mean differences and a lifelong process that parallels one’s development similarities may be irrelevant when applied to throughout the lifecycle. During childhood and a specific individual. adolescence, coming out might mean having a first same-sex crush, feeling different, or asking Although it is likely that there are more simi- oneself, “Am I gay?” Later in adolescence or larities than there are differences in the develop- during young adulthood, coming out includes mental trajectories of gender and sexual first same-sex intimate experiences, relationships, minorities as compared to the general population, and telling friends and/or family. Although every there are some key areas of difference that are individual uniquely identifies on the sexuality important to keep in mind when working with continuum, those who identify as a sexual people on the gender and sexual continuum. The minority must make decisions every day about first is that many gender and sexual minorities whether or not to disclose their sexual identity, recall “feeling different” from their peers particularly during times of major life change, beginning around 7 or 8 years of age. Often, this such as moving to a new town or starting a new feeling is a result of gender-“atypical” or gender- school or job [3]. Younger generations seem to be “nonconforming” behavior. As many as two- coming out at earlier ages and often feel no need thirds of adult gay men and women recall some to label themselves at all. Older generations, who gender-atypical behaviors or preferences as chil- came of age during more conservative times, may dren [13]. In the United States, “tomboys,” or have gotten married to opposite sex partners, had girls who prefer boys’ toys, games, clothing, and children, and begun the process of coming out playmates, tend to have fewer problems with much later in life. There is likely a similar but social adaptation than “sissy boys,” or boys who somewhat different process of coming out for prefer girls’ toys, activities, dress, and playmates, gender minorities. The process may start earlier as evidenced by our socially constructed labels in life during childhood or adolescence and may for these two subsets of children [3]. be complicated by the need to make important Notably, children who display gender role decisions about puberty suppression in behaviors that are more typical for the opposite conjunction with their legal guardians and sex will sometimes come to the attention of their medical and mental health providers. parents, peers, or communities for violations of The Group for the Advancement of typical gender role behaviors. Gender identity Psychiatry’s online LGBT Mental Health and gender role behaviors often align, but not Syllabus serves as a rich resource in exploring the always. Many children with cross-gendered unique issues facing same-sex couples and behaviors impactful enough to qualify for a individuals through adulthood, including diagnosis of gender identity disorder grow up to variations in intimate relationships, civil unions have persistent gender-nonconforming identities, and marriage, parenting, and aging [3]. Although but a vast majority of those children as they grow the US Supreme Court ruled in 2015 that the 12 Not by Convention: Working with People on the Sexual and Gender Continuum 239

Defense of Marriage Act (DOMA) and its the specifics for each individual and help to avoid restriction of the federal recognition and the unfortunate experience of bias that many definition of “marriage” to only include opposite- LGBTQ patients face in their medical care. But sex couples was unconstitutional, the variability before an assessment can be completed, a person of nondiscrimination policies within individual must first seek care. states continues to obscure the rights of same-sex Because of accrediting organizations, enthusi- couples and perpetuates systematic discrimina- astic students, trainees, and faculty as well as in tion against the LGBT community [29]. Despite response to the pressure from LGBTQ rights barriers to reducing anti-LGBT rhetoric organizations, most training programs include societally, the legalization of same-sex marriage some form of training on sexual and gender had a significant impact on the visibility and minorities. Yet despite the increase in training, normalization of sexual minority identities in the LGBTQ individuals continue to experience sig- United States. Notably, the Youth Risk Behavior nificant bias in their doctor’s offices. In a recent Surveillance System (YRBSS) sampled more large national survey of transgender individuals, than 700,000 high-school students and found a 24% of all respondents were denied equal care at significant decrease in the rate of suicide attempts a doctor’s office or hospital and nearly 19% of among sexual minorities living in states with pol- respondents were denied care altogether. In addi- icies recognizing same-sex marriages [30]. The tion, over one-quarter of respondents were ver- American Academy of Pediatrics (AAP), bally harassed at their doctor’s office. Not American Medical Association (AMA), surprisingly, those surveyed were less likely to American Psychological Association (APA), seek care in part because of a legitimate fear of American Psychiatric Association (APA), and harassment [32]. National Association of Social Workers (NASW), Much can be done to set the scene prior to the among other professional organizations, healthcare professional even meeting the patient explicitly support and recognize the positive to reduce a person’s fear of bias or discrimina- impact policies that support same-sex marriage tion. Review your intake documents and elec- have on the rights, benefits, and long-term secu- tronic medical records from the viewpoint of an rity of children in the United States [31]. LGBTQ individual. How does a transgender man identify gender when given only the option of male or female? How do same-sex parents dif- Assessment ferentiate themselves when given the option of mother or father? When a person has legal docu- Assessment Overview Within ments identifying them as one gender but they a Biopsychosociocultural Framework identify as the other, how do you ensure their preferred name and pronouns are used? Are there At all ages and in every culture, every person has gender-neutral bathrooms available for use? Are a gender identity, and as cognitive and physical there questions about sexual orientation in the development progresses, every person develops a documents, and are they asked in such a way that sexual orientation as well. The details, meaning, allow for the large spectrum of responses? For and impact of those identities can fluctuate over many patients and families, an early opportunity time, and there is a great deal of evidence to to create an environment that is respectful and suggest that sexual orientation and gender affirming of the needs of LGBTQ patients is identity are on a spectrum. However, if we are not with front-desk staff. Training front-desk staff able to sensitively ask the questions, our patients about the unique healthcare needs and barriers of will never provide us with the answers that can LGBTQ patients and families can improve the help inform a comprehensive treatment plan extent to which institutions provide responsive targeted to each patient’s individual needs. A healthcare experiences consistently. Affirmative thorough and thoughtful assessment can capture Care for Transgender and Gender Non- 240 J. A. Wernick et al.

Conforming People: Best Practices for Front- variations in their gender expression or sexual line Health Care Staff is a valuable training orientation, but everyone proceeds through iden- resource developed by the National LGBT tity development around their sexuality and gen- Health Education Center [33]. By giving LGBTQ der, and often exploratory behaviors and thoughts patients and families a space for their identities in youth are not reflected by later identity con- to be acknowledged, you are already improving solidation in adulthood. Regardless if one identi- their care and potentially alleviating fears of fies as gay, straight, bisexual or asexual, possible bias and discrimination. When meeting cis-gendered, transgendered, or genderqueer, at the patient for an initial assessment, it is vital not a certain point, a sexual orientation and gender to make assumptions and to stress confidential- identity are established, and frequently those ity. A curious stance with open-ended questions early exploratory thoughts, fantasies, or experi- is recommended to allow patients the flexibility ences are forgotten. In one study, men reported to answer honestly about their gender and sexual same-sex experience rates of approximately 3% development. It can be tremendously helpful to for the past year and 7–9% since puberty, and for display materials that identify you as someone women, approximately 1% in the past year and comfortable speaking with sexual or gender 4% since puberty [36]. These numbers reflect minorities, or alternatively, it can be helpful to sexual behavior only and do nothing to quantify normalize a wide range of identities and behav- identity or fantasies, nor are these numbers pre- iors. Often, questions are directed either at iden- dictive of later identity. They capture behaviors tity or at behavior, but not at both. Identity does but miss out on the fuller picture of the diversity not equal behavior, and a person telling you they of gender and sexual expression. are heterosexual in no way completely defines As a society, we are much more comfortable their sexual behaviors or fantasies. Only by ask- with identifying folks on opposing poles than as ing about identity and behavior as well as the on a spectrum. This stressor becomes very clear meaning of both will you start to get a clearer in work with bisexual or gender-queer individuals, picture of your patient’s internal sense of gender those who choose to identify on a place on the identity and sexual orientation. Literature sug- gender and sexuality spectrum that places them gests that neither sexual orientation nor gender apart from the current norm. By identifying in identity is a choice and that there are clear bio- such a way that may be more internally consistent logical influences on the development of sexual but less societally sanctioned, people are exposed orientation and gender identity. For example, to more bias and discrimination [37]. Those iden- twin studies investigating homosexuality [34, tifying as somewhere in the middle between gay 35] showed higher rates of concordance among and straight, man or woman, are often the most monozygotic twins (52% for gay men, 48% for misunderstood, and a good assessment is the first lesbians) than for dizygotic twins (22% for gay step to understanding. men, 16% for lesbians) and for adoptive siblings By thinking in a continuum approach, you are (11% for gay men, 6% for lesbians), thus making not limited to rubrics based on one identity or a clear argument for a strong heritable compo- another. Every person, no matter their orientation nent of homosexuality. However, how one or behavior, has biopsychosocial and cultural expresses those identities does involve a degree influences that define and modulate their gender of volition and is influenced by one’s psycho- and their sexuality. As such, age-appropriate logical, social, and cultural influences. This is as assessment of psychosexual development should true for identities considered more normative be done for every patient, and ideally, any than for identities less typically a part of the assessment would be structured such that the norm. provider can better understand the role that these The process of “coming out” is primarily an biopsychosocial and cultural influences have experience thought to be limited to those with played in their patients’ lives. 12 Not by Convention: Working with People on the Sexual and Gender Continuum 241

There is not good data on the prevalence of Comorbid Medical and Psychiatric gender variance, with most of the data coming Concerns either from the specialized gender clinics or patients presenting for cross-hormone treatment From the LGBT Mental Health Syllabus [3]: or sexual reassignment surgery. Numbers range [Those living on the gender and sexual continuum] from approximately 1 in 1000 to 1 in 20,000 indi- are people first and foremost, with the same viduals [38, 39], and these numbers do not primary care issues and needs as others across the account for those individuals that have an identity lifecycle. [This] community is highly diverse, and any discussion of health risks and behaviors runs that fits somewhere along the gender spectrum the risk of overgeneralization or even stereotyping, that do not seek any treatment. leading to questionable assumptions. Psychologically, one must understand how one integrates their gender and sexual orientation Our knowledge base with regard to medical into their identity. Have they fully formed their and mental health concerns facing gender and identity? Does it align with their behaviors? Does sexual minorities is limited by two key factors: it bring pride, shame, or indifference? What is the impact of their identity and behavior on their 1. There have been significant methodological mental health (substance use, depression, sui- challenges in conducting research on a group cidal ideation) or in their relationships—roman- that is subject to bias and discrimination, both tic, sexual, or otherwise? Often those with within society and within the medical system. gender-nonconforming identities or behaviors or 2. Until recently, those living on the gender and those with same-sex interests are forced to keep sexual continuum have not been included or their identities and experiences a secret—from adequately identified and characterized within their peers, from their families, and even from important population health-based studies. themselves. How does holding on to that secret impact their development and their functioning? That being said, what follows is a review of There is no evidence to suggest that LGBTQ key health issues to consider in your work with all individuals use any separate defense mechanisms patients on the continuum keeping in mind that to address their challenges [40]. However, for risk is conferred by gene–environment interac- those with sexual identity and/or gender identity tions and behavior and not by sexual orientation that is not safe to be expressed, they often miss or gender identity. It is important to ask about spe- out on developmental experiences they see their cific sexual and health-related practices, such as peers engage in. how often they see their healthcare providers, Socially and culturally, inquiries can lead into level of trust in the medical system, and willing- multiple social milieus. For example, what are ness to follow-up with recommended screenings the family beliefs about sex, gender, and sexual- or treatments, to accurately assess medical and ity? What are the community and/or religious mental health risks in our clients. views about gender and sexuality? Does the patient face bias? Is he or she safe to express his or her identity? What are the cultural values and Cancer mores of the social group? Do you know people that are going through a similar developmental Though definitive studies are lacking, prelimi- trajectory? Asking these types of questions will nary data suggests that sexual and gender minori- help a provider to understand the context through ties have a heightened risk for certain cancers. which his or her patient conceptualizes their gen- More research is needed to understand the natu- der and sexuality and helps to later guide the ral history of disease in these populations. MSM treatment plan. have higher rates of non-Hodgkin lymphoma and 242 J. A. Wernick et al.

Kaposi’s sarcoma associated with HIV/AIDS in the United States, MSM have been the largest infection. Evidence increasingly suggests that subpopulation affected. Although the popular MSM are at increased risk for anal cancer due to image of a person with HIV/AIDS is of a White increased rates of human papillomavirus (HPV) gay man, African Americans account for 46% of and, as of yet, lack of standardized screening in those living with HIV with Latinos accounting this population. HIV-positive MSM should have for 18% and Whites accounting for 35%. New yearly anal PAP tests, and those who are HIV HIV infection rates remain disproportionally negative should be screened every 2–3 years. The high among younger African American and HPV vaccine is under study for the MSM Latino MSM [43]. population. Because the risk for HPV and anal Since AIDS was first recognized in 1981, we cancer travels with sexual behavior and not have made great strides in the prevention of sexual orientation, it is important to also inquire HIV transmission and in HIV/AIDS care. The about current and historical sexual practices Center for Disease Control (CDC) estimates while working with all of your patients and not that 1.1 million people in the United States are just those who are self-identified homosexuals. living with HIV infection and that approxi- Though no definitive studies have been com- mately 1 in 5 (21%) of those people are unaware pleted, lesbians may be at higher risk of breast of their infection [42]. With the advent of highly cancer than heterosexual women due to higher active antiretroviral treatments (HAART), what rates of risk factors, such as obesity, alcohol con- was once a nearly certain fatal disease has sumption, nulliparity, and lower rates of breast become a chronic disease for those who have cancer screening. Lesbians also tend to receive access to treatment [3]. The availability of less frequent gynecologic care than heterosexual HAART not only increases the lifespan of those women and might also be at higher risk for with HIV infection but also lowers some peo- greater morbidity and mortality from gyneco- ple’s perception of risk and thus their behavior logic cancers, such as uterine and ovarian cancer. around unprotected sex and needle sharing. The Women who have had sex with women (WSW) long-term sequela of HAART, such as high should be screened with PAP and for HPV as per cholesterol, diabetes, and the redistribution of the established recommendations for all women body fat, need to be monitored closely by pri- and vaccinated against HPV when appropriate [3, mary care, medical specialist, and mental health 41]. professionals. The health implications of HIV are far- reaching and range from life-threatening HIV/AIDS opportunistic infections and malignancies to mental health challenges. Although significant The human immunodeficiency virus (HIV) is the medical advancements have improved the infectious agent that can lead to acquired immune treatment of HIV in the United States, access to deficiency syndrome, or AIDS. HIV is spread preventative care continues to be complicated through direct contact with an infected person’s and challenging for members of the LGBT blood, semen, vaginal secretions, and breast community. Oral pre-exposure prohylaxis (PrEP) milk. The HIV/AIDS epidemic has had enormous is a once-daily pill that can significantly reduce impact on global health, and patterns of an HIV-negative person’s risk of getting HIV transmission vary greatly between countries. In through common high-risk exposures, such as 2011, an estimated 34.2 million people worldwide sexual activity or injection drug use. Despite its were living with HIV, and there were 2.4 million efficacy and approval by the Centers for Disease new cases of HIV infections in 2011 alone [42]. Control (CDC), US Food and Drug Administration Worldwide, unprotected sexual contact between (FDA), and US Public Health Service, few people of the opposite sex accounts for more healthcare providers are appropriately trained in cases than those for same-sex contacts. However screening for PrEP eligibility. Improving access 12 Not by Convention: Working with People on the Sexual and Gender Continuum 243 to services across the HIV care and prevention The most common types of viral hepatitis, or continumm requires training medical and mental inflammation of the liver, are hepatitis A, B, and health professionals to screen and counsel all C. All three of these unrelated viruses can patients on safer sexual practices and appropriate produce an acute illness characterized by nausea, adherence to preventitive medications [44, 45]. malaise, abdominal pain, and jaundice. Many Those reporting higher-risk behavior, such as persons infected with hepatitis B or C, which are multiple partners, unprotected sex, needle transmitted through contact with an infected sharing, or sex with partners who are sharing person’s blood or body fluid, are unaware they needles, should be screened more frequently, are infected. Both hepatitis B and C viruses can approximately every 3–6 months [3]. produce chronic infections that often remain Professionals may erroneously assume that clinically silent for decades while increasing risk lesbians have had no history of sexual contact for liver disease and liver cancer [46]. Vaccines with men. In one study, 77% of self-identified are available for hepatitis A and B. Due to an lesbians had one or more male sexual partners in elevated risk for hepatitis A and B in MSM, all their lifetime. WSW appear to have higher rates MSM should be adequately vaccinated though of unprotected sex when having sex with men, many are not. more sexual contact with MSM, and more sexual contact with IV drug users when compared with exclusively heterosexual women [43]. These sta- Mental Health and Substance tistics demonstrate the importance of screening Abuse WSW for HIV along with women who are not sexual minorities. Gender and sexual minorities have higher prevalence of depression, anxiety, substance use disorders, suicidal ideation, and posttraumatic stress Other Sexually Transmitted disorder. Some researchers hypothesize that the Diseases and Hepatitis cause of the higher prevalence of these disorders is partially attributable to societal stigma, preju- Because STDs and the behaviors associated with dice, and discrimination against gender and sex- acquiring them increase the likelihood of acquiring ual minorities, which in turn leads to stress and and transmitting HIV, it is important that all patients mental health problems. This hypothesis, the be screened and counseled on safer sex practices minority stress theory, will be discussed in fur- and other preventative measures. Some surveil- ther detail in the next section. In the few larger- lance data suggests that rates for syphilis and gon- scale, national epidemiologic studies, suicidal orrhea may be increasing among MSM. The ideation and attempt rates approach or exceed current recommendation is that MSM should be 50% and 20%, respectively. Recent studies of screened yearly for gonorrhea, syphilis, chlamydia, sexual minority youth populations continue to herpes, HPV-associated genital and anal warts, and report alarmingly high rates of suicidal ideation HIV. MSM are also at increased risk for proctitis, and attempts at 3–7 times higher prevalence as pharyngitis, and prostatitis, which are infection and compared with heterosexual youth [42]. However, inflammation of the rectum, throat, and prostate, some research demonstrates that gender diverse respectively [41]. In terms of risk for lesbians and youth whose identities are supported experience WSW, there have been confirmed cases of trans- comparable rates of psychopathology to their cis- mission of herpes, HPV-associated anal and genital gender peers, and parental rejection may be an warts, bacterial vaginosis, and trichomoniasis. essential predictor of psychological functioning Despite these risks, lesbians and WSW are screened in adulthood [47]. With regard to substance use, and counseled on safer sex practices less frequently gender and sexual minorities have higher rates of than exclusively heterosexual women by their tobacco use, which is associated with increased healthcare providers [41]. risk for heart disease, lung cancer and emphysema, 244 J. A. Wernick et al. and a variety of other health problems. Studies described along a continuum from distal stressors, indicate that gender and sexual minorities have which are usually objective events and conditions, higher rates of alcohol and illicit drug use. All to proximal personal processes defined as patients should be routinely screened for alcohol subjective because they rely on individual per- and substance use disorders, especially since use ceptions and appraisals [48]. is associated with other high-risk behaviors and Starting with distal effects, studies have shown negatively affects other chronic diseases. that gender and sexual minorities are Clinicians should be familiar with some illicit disproportionally exposed to prejudice events, drugs used more frequently among gay men, including discrimination and violence. For such as inhalants, hallucinogens, and the “club example, LGB adults are twice as likely as drugs,” such as ketamine, MDMA (ecstasy, heterosexual people to have experienced a life Molly), methamphetamine (crystal meth), and event related to prejudice, such as being fired GHB. A few studies have included lesbians and from a job. Furthermore, 20–25% of lesbians and have found higher rates of tobacco, marijuana, gays have experienced victimization, including cocaine, and alcohol use as compared to hetero- physical and sexual assault, robbery, and property sexual women [3, 42]. crime. School-based studies suggest that gender and sexual minority youth are much more likely to be victimized by antigay prejudice events than Minority Stress Theory: Prejudice, heterosexual peers and that the psychological Social Stress, and Health impact of these events can lead to severe negative developmental outcomes. Ilan H. Meyer and others have written extensively Stigma, or a mark of shame or disgrace, placed on the topic of minority stress as a possible upon gender and sexual minorities by society leads explanation for why gender and sexual minorities to expectations of rejection and discrimination have higher prevalences of mental health within the minority group [48]. These minority problems, substance use, and perhaps medical groups learn to become “constantly on guard” or morbidity and mortality as well. In psychology, vigilant that others that they come across in daily stressors are defined as events and conditions, life might be prejudiced against them. Moving such as the death of a loved one, job loss, or new more proximally to the self, those living on the illness diagnosis, that cause change and require continuum often have to conceal their stigmatized that an individual adapt to a new life circumstance identity to avoid negative reactions from others. or situation. These situations include social However, there is a psychological cost to conceal- conditions, which strongly impact the lives of ment as one’s energies and cognitive processes those belonging to stigmatized social groups. become disproportionately consumed and siphoned According to Meyer and other stress researchers: to this end. There have been many studies describ- Prejudice and discrimination related to low ing the adverse psychological, health, and job- socioeconomic status, racism, sexism, or related outcomes due to workplace fear of homophobia—much like the changes precipi- discrimination and concealment around sexual tated by personal life events that are common to minorities. Although experiences of discrimination all people—can induce changes that require and societal stigma negatively impact the psycho- adaptation and can therefore be conceptualized logical well-being of all minority groups, a grow- as stressful [48]. ing body of research suggests that social support The minority stress framework describes four and perceived acceptance may be protective against underlying stress processes: (1) experience of the aforementioned risks. Furthermore, sexual and prejudice events (discrimination), (2) expectations gender minorities who are supported in the expres- of rejection (stigma), (3) hiding and concealing, sion of their identities experience developmentally (4) internalized homophobia, and ameliorative normative distress and psychopathology, and the coping processes. These stress processes can be literature shows that expressing emotions and 12 Not by Convention: Working with People on the Sexual and Gender Continuum 245 sharing important aspects of one’s self with oth- female or an Asian-American, transgendered man) ers—through confessions and disclosures in mean- can also connect with others from similarly diverse ingful relationships—are important factors in backgrounds to create opportunities for social sup- maintaining physical and mental health [49]. port and further integration of their complex iden- Internalized homophobia, or the internaliza- tities. Religious and spiritual affiliations and tion of societal antigay attitudes, within lesbians, institutions can also play a powerful role in one’s bisexuals, and gay men, represents what Meyer acceptance or rejection of same-sex attraction, describes as a form of stress that is “internal and behavior, and identity. Men and women have very insidious.” Research has shown that internalized different experiences of living on the gender and homophobia correlates with depression and anxi- sexual continuum based upon the unique develop- ety symptoms, substance use disorders, and sui- mental trajectories and socialization patterns and cidal ideation. Studies also suggest an association expectations for boys/men and girls/women within with self-harm, eating disorders, HIV risk-taking our society [3]. Other important realms to consider behaviors, and difficulties with intimate relation- in your work are the effects of socioeconomic sta- ships and sexual functioning [48]. tus, disability, and geography on the identity of Those living on the gender and sexual contin- those living on the gender and sexual continuum. uum also have access to powerful coping and resilience resources, such as opportunities for group solidarity and cohesiveness. Gender and Case BA: Assessment sexual minorities have created stigma-free, empowering environments that foster growth and After seeing BA for the initial evaluation, treat- integration of one’s gender and sexual identity ment focused on anxiety and panic attacks, and with other important aspects of one’s life. These BA was able to successfully attend high school. environments and relationships allow for a After a month of school, they reported continued reappraisal of the stressful condition, yielding it anxiety that was a function of feeling intensely less power to negatively impact upon psychologi- uncomfortable within their body. Through open- cal well-being [48]. ended questioning by the clinician, BA disclosed that they identify as agender and not as a female. During subsequent sessions, an assessment of Multiple Minorities gender and sexual development was undertaken. BA reported that they never felt female, and when Within each of us, we hold multiple identities. in elementary school and middle school, they did Gender and sexual identity are just two among not see this as an issue. BA identified that going many possible realms of self-definition and affilia- through puberty and growing larger breasts made tion, including those based upon socioeconomic them feel “less like themselves.” They reported status, geographic region, race and ethnicity, reli- that they did not ever experience any sexual gious and spiritual affiliation, and others. attraction toward others, though reported enjoy- Furthermore, within each of these groups, there is ing masturbation. They reported romantic feel- significant heterogeneity. Those who hold multi- ings toward individuals who present as feminine ple minority status may face unique struggles and but denied any sexual attraction to any gender. simultaneously have access to alternative social support networks and resources. For example, LGB people of color can face alienation and dis- Case SL: Assessment crimination by the LGB community and from their racial and ethnic community of origin, which Seeing SL for the initial evaluation, a full assess- sometimes leads individuals to feel forced to ment of gender and sexual development was choose one identity over the other [3]. Individuals undertaken in addition to psychiatric functioning. with multiple minority status (i.e., a lesbian, Latina SL reported that, for as long as he can remember, 246 J. A. Wernick et al. he felt uncomfortable conforming to “typical girly Treatment things.” Throughout elementary school, SL described feeling drawn to male peers and became Treatment Overview passionate about games and activities that made him feel “strong like the boys,” including karate, There is not a treatment for heterosexuality. Nor violent video games, and sports. SL experienced is there a treatment for homosexuality or significant rejection by male peers throughout bisexuality or gender variance. The scientific childhood, which he speculates was a result of his literature suggests that while one can, to some insistence on wearing dresses and pink clothing to degree, alter one’s behavioral patterns around “compensate” for the discomfort he felt socially sexual orientation and gender identity, it is not in gendered social contexts. SL began experienc- possible to change an enduring pattern or homo- ing significant symptoms of social anxiety around sexual or gender-variant development [50–52]. age 11 and started isolating himself to avoid dis- Attempts to change one’s sexual orientation comfort with female peers and rejection by male through therapy (at times known as “conversion peers. SL described first learning about transgen- therapy” or “reparative therapy”) have been der identities and gender nonconformity through practiced nearly as long as therapy has existed; the Internet at age 12 and recalls writing in his however, there is little evidence to support its diary, “I don’t think I’m totally a girl.” SL began efficacy. Anecdotal reports that speak to its exploring his gender identity in secret, referring to efficacy are counterbalanced by anecdotal reports himself using typically male names in the mirror, that speak to its lasting psychological harm. One taking photos with his hair tucked into a hat, and of the more controversial papers on the subject, participating in message boards with trans-indi- “Can Some Gay Men and Lesbians Change Their viduals online. SL’s willingness to begin sharing Sexual Orientation? 200 Participants Reporting a the more masculine aspects of his identity changed Change from Homosexual to Heterosexual after experiencing his first period at age 13, which Orientation” [53], argued that reparative therapy led to overwhelming distress associated with his may be effective for a small group of individuals anatomy. Since age 13, SL described feeling wishing to change their sexual orientation. “nauseated” by the round shape of his face, large However, in 2011, Spitzer retracted his claim, breasts, vagina, high-pitch voice, lack of body/ reporting “in retrospect, I have to admit I think facial hair, and noted feelings of disgust associ- the critiques are largely correct… The findings ated with his capacity to bear children. Around can be considered evidence for what those who age 14, SL described beginning to engage in have undergone ex-gay therapy say about it, but NSSIBs to alleviate feelings of hopelessness and nothing more” (http://prospect.org/article/my-so- negative thoughts about his body that impaired his called-ex-gay-life). The potential risks of this sleep and ability to focus during classes. SL did type of “therapy” include depression, anxiety, not disclose his anatomical dysphoria or gender self-destructive behavior, and the reinforcement identity questioning until he entered his first of the belief that sexual attraction toward the romantic relationship at age 16. SL began dating a member of the same sex or a gender identity that transgender female peer who shared her experi- doesn’t match one’s biological sex is pathological. ence transitioning socially and initiating hormone The American Psychiatric Association, the therapy. SL explained that exploring his sexuality American Psychological Association, the and gender expression with a supportive partner American Academy of Child and Adolescent helped normalize his preference for gender and Psychiatry, the American Academy of Pediatrics, sexual fluidity, leading him to come out to his par- and the National Association of Social Workers ents and a few close friends at school. SL noted all refer to the practice of reparative therapy as continuing to explore his gender and sexual iden- substandard and/or unethical care. So if changing tity and described himself as “mostly a boy and one’s sexual orientation or gender identity is not mostly attracted to feminine people.” a valid goal for treatment, what are appropriate 12 Not by Convention: Working with People on the Sexual and Gender Continuum 247 goals and special considerations for treatment of aware of professional and community resources LGBTQ patients? that can provide safe, supportive environments for LGBTQ individuals.

Recognition of Similarities Identification and Management First of all, it is important to note that there can of High-Risk Behaviors be more commonalities in treatment planning for a bipolar gay man versus a bipolar straight As described earlier in the chapter, LGBTQ indi- woman than there are between a gay man with viduals are more likely to be the victims of bullying social phobia and a gay man with schizophrenia. or systematic discrimination and more likely to A thorough assessment and diagnostic evaluation contemplate as well as attempt suicide. Data in this should first and foremost guide the treatment realm can be quite terrifying. Up to 40% of trans- planning. Standard, evidenced-based gendered adults have attempted suicide at least interventions should be put into place for any once in their lives [32]. Researchers have begun to primary psychiatric disorders. However, in investigate risk factors and demographics of those working with the LGBTQ population, context is more likely to attempt suicide in addition to inves- important. It is important to know the cultural tigating resiliency factors that are protective. norms, as well as the individual norms for the Treatment in many ways is guided by this research. patient you are treating. For example, sexual A stable sense of identity and a connection to a expression and the frequency of sexual encounters family/community that is supportive are two resil- can change based on the norms of the culture the iency factors that have been identified as protective patient identifies with. How does a treatment for suicide risk in youth populations [54, 55]. As provider recognize the manic symptom of such, the treatment provider has an opportunity to hypersexuality in the case of an asexual patient provide a safe space for a patient to explore their versus in a patient who routinely has multiple sex own identity free from judgment or free from partners each week? agenda. In this way, the therapist can “protect the individual’s full capacity for integrated identity formation and adaptive functioning” [56]. For chil- Identification and Management dren and adolescents, the presence of an interested of Psychiatric and Medical adult is protective against suicide for lesbian, gay, Comorbidities and bisexual youth, and the therapist can both fill that role and help their patients connect to commu- As described earlier in the chapter, LGBTQ indi- nity supports. Family interventions, particularly viduals have an increased risk for a number of when working with children and adolescents are psychiatric and medical comorbidities. The cul- vital to help build family connectedness and mutual turally sensitive provider will learn how to assess understanding of the patient’s exploration of their for these comorbidities and apply evidence-based gender and sexuality. practices to address them. A mental health professional need not identify as LGBTQ in order to provide a treatment environment free of bias; Understand and Intervene however, some LGBTQ patients will specifically on Stigma and Bias request having a provider with more personal understanding of what it means to be LGBTQ. It It is the job of the healthcare professional to is the responsibility of the provider to help con- understand the societal and cultural context by nect their patients to other culturally sensitive which their patient may be exposed to stigma and providers in order to reduce the risk of further bias and to help address and/or manage the psy- healthcare discrimination. It is important to be chological impact. In some schools and work- 248 J. A. Wernick et al. place environments, people are openly targeted their overall health, psychological well-being, for appearing gay, lesbian, or gender variant. and self-fulfillment.” The SOC provides Although Title VII of the Civil Rights Act of guidelines for mental health and medical 1964 protects employees from being fired based professionals providing care for gender-variant on their race, religion, national origin, or sex, individuals and seeks to establish evidenced- LGBT identities are not explicitly protected by based practices. They recommend that mental Title VII in the eyes of the federal government. health clinicians working with gender-variant Numerous unsuccessful attempts have been made individuals should have basic competence in to update the terms of Title VII, but for the major- mental health assessments and treatments in ity of LGBT employees in the United States, pro- addition to a knowledge of the range of gender- tection from discrimination in the workplace nonconforming identities and expressions and of varies by state, county, or even city. the assessment and treatment of gender dysphoria. It is not explicitly stated that LGBT employ- Ongoing education and supervision in the field is ees can be protected from termination based on vital to maintaining sensitivity and efficacy. their identities. As such, LGBTQ individuals As for any person, a good treatment begins often have to hide their identities at work or at with a thorough assessment. Assessment of school in order to protect themselves. As provid- gender-variant individuals “includes, at a ers we have the opportunity to educate potential minimum, assessment of gender identity and allies in these stigmatizing environments and gender dysphoria, history and development of help to build a safer environment for our LGBTQ gender dysphoric feelings, the impact of stigma patients. In addition, Medicaid policy dictates attached to gender nonconformity on mental that no coverage be provided for treatment related health, and the availability of support from fam- to gender identity-related concerns, nor do many ily, friends, and peers…” [57]. As described ear- other insurers. As such, a two-tier system is lier, gender-variant behaviors are more common created for gender-variant individuals—those in childhood than in adulthood, and most chil- that can afford the life-saving treatment and those dren meeting criteria for gender identity disorder who cannot. in childhood will no longer meet qualifications for that diagnosis as adults [58]. As such, it is important for the clinician to be “aware of current Special Considerations for Gender evidence on the natural course of gender discor- Variance dance and associated psychopathology in children and adolescents…” [56] as well as in adults. The World Professional Association for The health professional should provide educa- Transgender Health is an international, tion to their patients regarding options for gender multidisciplinary professional association with a identity expression and medical interventions and “goal to promote evidenced-based care, be able to assess for eligibility, preparation, and education, research, advocacy, public policy and referral for hormone therapy and surgery. At pres- respect in transgender health” (http://www. ent, the SOC recommends that if a patient is to wpath.org/about_mission.cfm). As a part of their begin puberty suppression or hormone treatment mandate, they publish the Standards of Care for (i.e., estrogen for a biological male with a female the Health of Transsexual, Transgendered, and gender identity or testosterone for a biological Gender Non-Conforming People. The overall female with male gender identity), a qualified goal of the Standards of Care (SOC) “is to mental health professional must first assess the provide clinical guidance for health professionals patient and provide a letter that identifies the to assist transsexual, transgender, and gender- patient’s personal and treatment history, progress, nonconforming people with safe and effective and eligibility. An understanding of the risks, ben- pathways to achieving lasting personal comfort efits, and alternatives must be demonstrated and with their gendered selves, in order to maximize the treatment options reviewed. It is a similar pro- 12 Not by Convention: Working with People on the Sexual and Gender Continuum 249 cess for either breast reduction/removal or aug- agender identification, it was recommended that mentation surgeries. For genital assignment BA socially transition. The clinician worked with surgeries, two separate qualified mental health BA on finding a safe chest binder and in professionals must provide support. Hormone facilitating conversations between BA and their treatment and surgery can be lifesaving, and the parents around their gender identity. The clinician literature suggests that relief from gender dyspho- and BA also collaboratively worked with BA’s ria cannot be achieved without a closer congru- school alerting teachers to BA’s preferred name ence between one’s gender identity and their and pronouns. This social transition improved primary/secondary sex characteristics [59–61]. BA’s ability to engage effectively in school. They Psychotherapy is not an absolute requirement reported improvements in mood and anxiety in for these referrals, nor is there one specific type of the classroom and felt affirmed in their gender therapy that is recommended. The goals of ther- identity with teachers and peers. BA continues to apy for gender-variant individuals are not mani- struggle with dysphoria related to their breasts festly different from anyone else—to maximize and is considering a breast reduction or chest well-being, self-fulfillment, and quality of life. masculinization when they graduate from high However, supporting a patient (as well as their school. They are not interested in hormone family and community) through a gender transi- therapies and report that they feel affirmed in tion is a unique task, and providers working with their gender through the use of gender-neutral transgender clients should have experience with pronouns from their family, friends, providers, this process. For example, the mental health pro- and school personnel. fessionals must educate themselves about the processes for changing one’s identity documents, advocacy options, and peer supports within the Case SL: Treatment Follow-Up gender-variant community. While there are unique aspects to treatment of SL began weekly therapy with a new mental the LGBTQ population, the process of treatment health provider to address the impact of gender is no different. Every person develops a sense of dysphoria on the mental health challenges and their gender and their sexuality, and every person risks impacting his ability to access hormone is profoundly influenced by these processes. To therapy. SL’s treatment initially focused on bring gender and sexuality into the treatment is to improving coping skills to reduce the severity of better understand and enrich the therapeutic life-threatening NSSIBs and rehearsing social relationship and encourage an open dialogue skills to address symptoms of social anxiety about identity that will have reaching impact impairing his capacity to appropriately elicit beyond the realm of gender and sexuality. social support. SL began to report improved social functioning at school and increased perceived support following participation in an Case BA: Treatment Follow-Up LGBTQ+ support group in his community. After a few months of reduced symptoms of anxiety BA engaged in weekly psychotherapy to address and depression, treatment began to focus on symptoms of panic disorder without agoraphobia, clarifying goals for social and medical transition. generalized anxiety disorder, and gender The mental health provider collaborated with SL dysphoria in adolescence. The first stage of and his parents to advocate for use of his preferred treatment focused on anxiety symptoms as BA name and pronouns at school and participated in did not report gender dysphoria until a few family sessions to prepare for sharing his gender months into treatment. After helping BA manage identity with extended family members. As a anxiety better at home and at school, treatment result of social transition across settings, SL focused on education regarding gender identity began to report reduced feelings of shame and development. Given BA’s strong and persistent hopelessness and the family participated in an 250 J. A. Wernick et al. initial consultation at a local clinic to receive patients’ lives, we can improve overall health information about the risks, benefits, and realistic outcomes and strengthen our therapeutic alli- expectations for initiating hormone therapy. As ances. Future directions for clinical work, SL’s parents assented to hormone treatment and research, and education are vast and include his mental health provider determined that his but are not limited to ensuring equal access to mental health was stable and reasonably well- and improved quality of care for those living managed, SL began receiving weekly injections on the gender and sexual continuums as well as of testosterone. After several months of hormone addressing the roots of stigma, discrimination, therapy, SL continues to experience significant and prejudice both within healthcare and soci- anatomical dysphoria related to his breasts and ety at large. genitalia and noted an increase in social anxiety in response to people commenting on noticeable changes to his body/facial hair and voice tone. References Although SL still struggles with accepting his gender identity and presentation without surgical 1. Conant E. In their words: how children are affected intervention, he continues to cope effectively by gender issues. National Geographic Special Issue: with urges to engage in self-harm and is working Gender Revolution. 2017. https://www.nationalgeo- with his mental health provider to develop an graphic.com/magazine/2017/01/children-explain- how-gender-affects-their-lives/. Accessed 30 July appropriate treatment team when he begins 2018. college. 2. Conant E, Henig RM. 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B. Heidi Ellis, Jeffrey P. Winer, Kate Murray, and Colleen Barrett

Introduction lion children) [3]; this represents a significant population to respond to clinically [4]. Global forced displacement remains at unprece- Importantly, status as a forcibly displaced person dented levels [1]. At the end of 2016, there were seeking refuge is not in itself a psychiatric condi- a record-high 65.6 million people forcibly dis- tion—refugee status is a sociopolitical phenom- placed, according to the United Nations High enon with common downstream psychosocial Commissioner for Refugees (UNHCR) [1]. With effects [5]. As refugees resettle in third-party 300,000 new people displaced in 2016, there countries, often after prolonged stays in refugee were 20 people newly displaced every minute of camps in a country or countries outside of their 2016. Most refugees flee their homes with little home, many experience mental health problems time to prepare [2] and, in turn, frequently are ill- associated with past trauma, ongoing stress, or equipped with the financial, linguistic, and other both. In order to effectively serve this population, resources needed to address the challenges of the mental health professionals including research- journey that lies ahead. The nature of the pre- ers, clinicians, educators, and policy makers will migration and flight experiences for refugees, need to understand the impact of the refugee which are frequently marked by fear, forced experience and cultural context on psychological departure, and experiences of torture and trauma, functioning. This chapter will review the unique distinguishes them from other voluntary migrants. mental health challenges of refugees and cultur- Since 1975 approximately 3 million individuals ally adapted assessments and treatments target- have been resettled in the USA across all 50 ing some of the world’s most vulnerable, yet states (approximately 2 million adults and 1 mil- resilient, populations. According to Article 1 of the United Nations 1951 Convention on the status of refugees, refu- B. H. Ellis (*) · J. P. Winer gees are persons who have crossed an interna- Department of Psychiatry, Boston Children’s Hospital/Harvard Medical School, Boston, MA, USA tional boundary because they are unable or e-mail: [email protected] unwilling to avail themselves of the protection of K. Murray their former country due to a well-founded fear School of Psychology and Counselling, Queensland of persecution based on race, religion, national- University of Technology, Brisbane, QLD, Australia ity, membership of a particular social group, or C. Barrett political opinion. Refugees are distinguished Department of Psychiatry, Boston Children’s from other forcibly displaced migrant popula- Hospital, Boston, MA, USA

© Springer Nature Switzerland AG 2019 253 R. Parekh, N.-H. T. Trinh (eds.), The Massachusetts General Hospital Textbook on Diversity and Cultural Sensitivity in Mental Health, Current Clinical Psychiatry, https://doi.org/10.1007/978-3-030-20174-6_13 254 B. H. Ellis et al.

Table 13.1 Definitions according to UNHCR 2018 the Democratic Republic of the Congo, Myanmar, global trends document and Iraq. Across these distinct geographies and Refugees Individuals recognized by the 1951 cultures, all are contexts where intractable Convention definition as persons who conflict, oppression, and violence are present. have crossed an international boundary because they are unable or unwilling to The countries of asylum in which the most avail themselves of the protection of refugees left from include Turkey, Lebanon, their former country due to a well- Jordan, Nepal, and Kenya [8]. The UNHCR founded fear of persecution based on projected global resettlement needs for 2018 are race, religion, nationality, membership of a particular social group, or political 1.2 million people [8]. For the most up-to-date opinion statistics on refugee resettlement trends, visit Asylum Individuals who have applied for www.unhcr.org. seekers international protection but their refugee While recognizing that the largest burden of status claims have not been verified supporting forcibly displaced persons around the Internally Individuals who have been forcibly displaced displaced but have not crossed an globe falls upon less economically developed persons international boundary. The UNHCR countries, the USA represents the largest refugee provides protection and/or assistance to resettlement program in the world (e.g., in 2016, conflict-generated displaced persons the USA received 66% of UNHCR’s refugee Persons of Individuals who do not fall into the concern previous categories but to whom the referrals) [8]. Together, the USA, Australia, and UNHCR provides protection and/or Canada resettle 90% of the global refugees within assistance based on humanitarian or the refugee resettlement scheme [7]. The other special grounds considerable number of refugees in the USA demonstrates that this is an important population tions including individuals who are internally for researchers, clinicians, educators, and policy displaced within their native country, asylum makers to recognize and to be prepared to seekers, or other persons of concern who have appropriately address. not yet been recognized by international bodies Over the course of history, the refugee resettle- as refugees (Table 13.1). The UNHCR was estab- ment process in the USA has been characterized lished in 1951 with the mission of coordinating by waves of different ethnic groups. Initial refu- international efforts for the protection of refugees gee legislation in 1948 brought a wave of Eastern [6]. The UNHCR identifies three durable solu- Europeans. Since that time the USA has wel- tions for refugees: (1) returning to their country comed populations from around the world includ- of origin once safety has been established; (2) ing, but not limited to, groups originating from integration into the country of first asylum, which Hungary, Cambodia, Vietnam, Cuba, Russia, is often a country neighboring the country of ori- Somalia, the Democratic Republic of the Congo, gin and where many refugee camps are estab- Bosnia, Croatia, Sudan, Myanmar, Nepal, Bhutan, lished; or (3) resettlement in a third country. Less Iraq, and Syria. The process of resettlement pro- than 1% of all refugees are resettled (option 3) in vides a critical international tool for providing any given year, with the largest numbers reset- safety among the world’s most vulnerable and at- tling in one of the nine most common resettle- risk populations. Although refugees arrive with ment countries (in alphabetical order): Australia, varied ethno-cultural backgrounds and diverse Canada, Denmark, Finland, the Netherlands, experiences pre-resettlement, they share experi- New Zealand, Norway, Sweden, and the USA ences of forced displacement, adjustment to a new [7]. country, a loss of resources and—for many—a In 2017, refugees from nearly 70 countries of history of trauma and/or torture. In addition to origin were resettled globally across 34 countries these common experiences, the constantly chang- around the world [8]. The largest numbers of ing nature of geopolitical conflict leads to great resettled refugees engaged in UNHCR programs cultural diversity among refugees; this incredible came originally from the Syrian Arab Republic, diversity of cultures within resettlement programs 13 Understanding the Mental Health of Refugees: Trauma, Stress, and the Cultural Context 255 each year, and over time, poses a significant chal- [13]. Though traumatic events experienced after lenge for resettlement agencies, mental health resettlement are less well documented in the providers, and host communities. Such cultural research literature, for some refugees, especially and ethnic diversity demands mental health ser- those resettled in low-resource and high-crime vices that are both cognizant of the common settings, exposure to trauma through neighbor- experiences and challenges of refugees while hood or domestic violence is an unfortunately remaining sensitive, thoughtful, and responsive to common occurrence [14]. the ways in which culture and history can shape Refugee children and adolescents have also experiences, symptoms, and attitudes toward and frequently been exposed to violence, deprivation, effectiveness of mental health interventions. As and at times, torture [15, 16]. Research with countries continue to resettle refugees from areas Somali adolescents suggests that, similar to of political unrest and violence, questions of how adults, refugee adolescents have experienced best to support the mental health and adjustment repeated trauma exposure [17]. While the term of these populations will be critical. “refugee mental health” has at times been used synonymously with “refugee trauma,” an overly narrow focus on trauma and its consequences Understanding the Refugee misses important aspects of the refugee Experience: Trauma, Resettlement experience that have direct bearing on refugee Stress, Isolation, and Acculturation health and well-being. While many refugees have experienced traumatic exposure, sometimes in For many people from a refugee background, the context of torture or widespread violence, devastatingly violent wars and/or torture are other aspects of stress that accompany the defining features of their experience. Studies resettlement process are also critical to understand vary widely in the reported rates of torture and in order to better serve refugee and forced migrant trauma among refugee populations, depending populations. Research suggests that in some on the origin of the refugee group and the cases, the stressors encountered in resettlement, circumstances of their persecution and flight. such as social isolation and discrimination, are One study of 353 refugees from multiple ethnic important predictors of mental health problems backgrounds in a Dutch refugee clinic found that and may account for a larger percentage of mental 37% of individuals reported incidents of torture, health symptoms than trauma exposure in one’s 37% reported being close to death, and 35% country of origin [18, 19]. For example, in a stated that a friend or family member had been study of Bosnian refugees, the strongest predictor killed [9]. Another study found that the proportion of depressive symptoms was current social of refugees who had been subjected to torture isolation, whereas past trauma history did not varied from 5% to 30%, depending on ethnicity predict depressive symptoms in this clinical and how torture was defined [10, 11]. A study of sample [18]. Experiences of discrimination are Kosovar Albanian refugees documented that common among refugee communities [20] and approximately 67% of refugees reported being may contribute to experiences of social isolation, deprived of water and food, 67% reported rejection, and identity invalidation and have been experiencing an active combat situation, and 62% found to be important predictors of both reported being close to death [12]. posttraumatic stress disorder (PTSD) and Importantly, refugees are likely to have expe- depression among resettled Somalis [18, 21]. rienced not one but multiple potentially traumatic Discrimination has also been found to predict events. In a study conducted within an African PTSD among adult Iraqi refugees [22]. refugee settlement camp, Somali refugees had Acculturative stress also plays an important experienced, on average, 12 separate traumatic role in refugee mental health. Acculturative stress event types and Rwandese refugees had experi- includes both the challenges of navigating a new enced, on average, more than 8 traumatic events country, such as learning a new language and 256 B. H. Ellis et al. cultural norms, and stress that occurs within a larly difficult to recover from in the context of family system as parents and children adapt to the ongoing stressors of acculturation, resettle- their new home in different ways and often at ment, and isolation [25]. The authors have sum- different paces [23]. Conflicts between children marized the four core stressors below; further and parents over cultural values, or new information on these stressors and the ways in responsibilities that fall to a child such as which they guide assessment and treatment translating important legal or educational planning is available through the Refugee documents or acting as an impromptu interpreter Trauma and Resilience Centerwebsite at https:// during a medical appointment, can all contribute is.gd/Corestressortool. to high levels of acculturative stress. Broadly, acculturation gaps between family members can disrupt previous family hierarchies, values, and Mental Health Needs communication practices. Here, again, research suggests that trauma is less primary in the In part because of the high rates of trauma expo- etiology of mental health problems than sure and significant stressors during resettlement, acculturative stressors; in a study of 447 Southeast individuals and families with refugee back- Asian refugees, post-migration stress associated grounds are at risk for elevated psychological dis- with acculturative tasks was a stronger predictor tress. Much of the research on refugee mental of psychological health than pre-migration health focuses on trauma-related outcomes, such trauma and stress [24]. While acculturative stress as rates of PTSD [26–28]. Prevalence estimates of may be particularly high for new arrivals, for psychological disorders vary widely and are likely many refugees, it remains high even years after influenced by both the methods used to assess resettlement. Importantly, the particular nature of prevalence (e.g., survey vs. diagnostic interview) acculturative stress may change or evolve over and cultural differences in symptoms and open- time. While the initial challenge of finding ness to reporting symptoms [27]. familiar foods to cook with or learning the Most estimates suggest rates of PTSD are transportation system may decrease with time, higher in refugee compared to non-refugee stress associated with concerns about one’s populations. One meta-analytic study calculated children losing or changing their cultural identity prevalence rates of 9% for PTSD among refugee and practices may intensify over time. In addition adults and 11% for PTSD among refugee to the culture-specific stressors of acculturation, a children, which places refugees at roughly ten number of additional stressors of resettlement times the risk for PTSD than their age-matched that are not unique to refugees, but that refugees counterparts [26]. Other studies suggest ubiquitously experience, are also important prevalence rates range from 4% to 44%, with predictors of mental health. Access to basic larger and more rigorously designed studies resources such as housing, jobs, and transportation identifying an average of 9% prevalence for is a key challenge faced upon resettlement and PTSD [26]. Refugee adults were also at elevated can play an important role in adjustment and risk for major depressive disorder (MDD), with well-being. rates ranging from 2% to 18% across studies with Taken together the research points toward the an average rate of 5% across studies with more importance of broadening the lens through than 200 participants. A systematic review of 181 which refugee mental health is understood from studies of adults who had experienced conflict a focus on refugee trauma to an emphasis on and displacement showed a weighted prevalence refugee core stressors, which include trauma, of more than 30% for both PTSD and depression resettlement stress, acculturative stress, and iso- [29]. In a meta-analytic study that included over lation/discrimination. These core stressors may 16,000 refugees, researchers found prevalence have a multiplicative effect in that the experi- rates that ranged from 4.4% to 86% for PTSD, ence of trauma pre-migration may be particu- 2.3% to 80% for depression, and 20.3% to 88% 13 Understanding the Mental Health of Refugees: Trauma, Stress, and the Cultural Context 257 for anxiety in war-exposed refugee adults [30]. refugees with a PTSD diagnosis. Whether Across the studies examined in this meta-analysis refugees in general are at an elevated risk for (29 in total), clinical prevalence rates were almost suicide, or whether some refugee groups are at always 20% and higher. While these large decreased risk for suicide due to cultural or prevalence ranges make population-based religious taboos, is not yet fully understood. estimates difficult, we can confidently say that However, given the high rates observed among rates of stress-related psychiatric illness among Bhutanese refugees, suicidality is an important refugees are much higher than that of their non- area to assess and consider within refugee mental refugee peers [27]. health. Research has largely indicated a dose– In addition to trauma- and stress-related out- response effect of psychological distress among comes, refugees may also experience other men- refugee and forced migrant communities; with tal health disorders at higher rates than increasing levels of exposure to torture and non-refugee populations. In children, higher rates trauma, there are associated increased symptoms of autism have been noted among children of of psychological distress [31]. The extent of Somali refugees [43]. In adults, rates of schizo- perceived life threat has been linked to the phrenia appear to be higher among refugees than magnitude of symptoms of anxiety and PTSD nonmigrants [44]. Among children, Fazel et al. [32, 33]. Furthermore, research indicates [28] identified two studies of psychotic illnesses individuals with more than one diagnosis (e.g., in which 2% of 226 adult refugees were diagnosed PTSD and MDD) have worse prognosis in with a psychotic illness. While elevated rates for resettlement [34]. numerous disorders have been identified within Increasingly, attention has been drawn to the the literature, the limitations of existing tools in suicide rate among refugees after resettlement. terms of cultural validity and available norms Since 2007, more than 56,000 Bhutanese refugees must be acknowledged. We discuss these issues have resettled in the USA, and in early 2009, in further detail later in the chapter. increasing numbers of suicides in this population The prognosis of mental health problems were being reported. By February 2012, 16 over the course of resettlement is quite variable. suicides among Bhutanese refugees in the USA Several studies have shown that the prevalence were confirmed, which translates to a rate of of mental health problems drops significantly 20.3/100,000 and is comparable to the rate of over time following resettlement [45, 46]. 20.76/100,000 that was confirmed from an However, other studies have found that elevated assessment done in refugee camps in Nepal [34– mental health symptoms may remain for decades 38]. These figures are notably higher (e.g., almost following resettlement [46–48]. Steel and col- double) than the USA rate of 12.4/100,000 [39]. leagues [49] found that psychological disorders There is some evidence that the presence of dissipated over time for the most part, but for a trauma and/or PTSD is associated with an subset of highly traumatized individuals, the increased risk of suicide among refugees [40, risk for psychological distress remained high 41]. Bhui and colleagues [42] investigated trauma for up to a decade after resettlement. This find- history among refugees and found that suicidal ing suggests the importance for more prospec- ideation was more common among those who tive research designs that are better able to experienced pre-migration shortage of food and determine different trajectories of adaptation serious injury and those who felt close to death. over the years following resettlement. Moreover, Within a study of Bhutanese refugees resettled in research that examines resilient responses to the USA, those who had experienced their house trauma and adversity will help advance inter- or shelter being burned down prior to resettlement ventions and programs that promote health and were four times more likely to report suicidal successful adaptation among those that are ideation [35]. Ferrada-Noli et al. [40] found a struggling with mental health and other adapta- high incident rate of suicide attempts (40%) in tion challenges. 258 B. H. Ellis et al.

Experiences in resettlement vary widely for elevated even 12 years after resettlement [55]. different age groups, genders, and cultural Among refugee youth, the nature of psychosocial groups; in turn, some are at greater risk for poor problems may change over time; youth resettled mental health outcomes. In general, being older for a longer period of time may become more or female has been associated with worse vulnerable to substance use, gang involvement, outcomes in resettlement [27, 50, 51]. In addition, and other conduct problems. This finding may refugees from rural backgrounds, those with seem counterintuitive, that maladaptive outcomes higher levels of education, and those with higher increase across resettlement, but as youth pre-displacement socioeconomic status (SES) acculturate to the USA (e.g., learn English, learn are more likely to report worse outcomes [27]. adolescent cultural norms), they are more likely While the finding that higher pre-migration SES to engage in both the adaptive and maladaptive and education are associated with worse social behaviors that impact youth who grow up outcomes may appear counterintuitive, the loss in the USA. of resources has been identified as particularly Among children and adolescents, individual, detrimental to recovery from trauma [28]. family, and contextual factors are all important in Individuals with higher status and greater supporting mental health outcomes [16, 56, 57]. material resources before migration must contend At the individual level, exposure to violence, with a dramatic change in these resources (e.g., a physical, psychological, or developmental former physician now working as a hospital disorders, time since displacement, sex, and level custodian), representing a loss of interdependence of education can influence outcomes. Families and past aspirations. The experience of loss (e.g., play a central role in the lives of refugee children; loss of family members, culture, and ways of life) families often flee in part to protect their children also demonstrates a unique contribution to reports from violence in their home countries. Parents of trauma symptoms as well as loss distress [52]. and families continue to serve as what has been Thus, the experience of loss (both traumatic and called the child’s “protective shield”—buffering non-traumatic loss) is an important factor that children from the world of stress around them. predicts psychological distress in refugee Yet for many refugee parents, the challenges of populations. navigating a new culture, establishing a new life in a new country, and managing their own physical and mental health needs may make it Mental Health Needs of Child difficult to provide the same kind of protection and Adolescent Refugees that they capably provided in their home countries. Unfamiliarity with language, culture, Prevalence estimates of mental health problems and school systems, their own trauma and related among refugee children and adolescents vary struggles, and the challenges of making a living widely. Estimates suggest that between 10% and in a new country can all limit parental capacity to 69% develop trauma-related mental health protect and assist one’s children. Some refugee problems [53, 54]. Other studies of refugee children lose parents or other important family children have also documented elevated rates of members through death or separation. The degree other disorders, such as depression, anxiety, to which a refugee family remains intact and able somatic complaints, sleep problems, and to nurture children plays an important role in the behavioral problems [15]. child’s mental health outcomes [33]. Thus many As with refugee adults, outcomes over time factors, above and beyond past trauma, influence can vary; a study of Cambodian adolescents child and adult refugee outcomes. These factors, followed into adulthood documented that and their relevance to mental health outcomes, depressive symptoms diminished significantly suggest the importance of widening intervention over time, but that PTSD symptoms remained targets beyond a trauma-only focus. 13 Understanding the Mental Health of Refugees: Trauma, Stress, and the Cultural Context 259

Resilience and Positive Responses Barriers to Care to Forced Migration Despite elevated levels of mental health distress, While significant research has identified the relatively few refugees access mental health ser- understandable mental health needs common vices. In a national study of Asian American/ among refugees, there is a growing emphasis on Pacific Islanders, mental health services were uti- promoting an understanding of positive lized at 1/3 the rate of non-refugee Americans adaptation and recovery from adversity and [64], and among refugee children and adoles- trauma. In general the prominent response to cents, as many as 92% of those in need do not adversity and trauma is that of the capacity to access appropriate mental health services [65– sustain functioning and even to thrive [58, 59]. 67]. While mental health access rates are likely to There are also instances where refugees may vary by specific ethnic group and other demo- develop high levels of mental health symptoms graphic characteristics, the generally low use and continue to function at very high levels [60]. rates suggest that focused attention to service There is a growing focus on research that access among refugees is needed. Practical examines well-being and adaptive outcomes [61] knowledge gained by refugee providers and part- independent of pathology and distress. nerships with refugee communities, as well as the Papadopoulos [5] highlights that not only do extant academic research, have highlighted key people frequently survive horrific conditions barriers to refugees receiving mental healthcare largely intact but that they may also be [29, 68]. Common barriers include (a) distrust of strengthened by their experiences through authority and/or systems, (b) stigma of mental adversity-activated development. This refers to health services, (c) linguistic barriers, and (d) pri- the process in which exposure to adversity macy and prioritization of resettlement stressors. requires transformation and adaptation in order Mental health promotion among refugees to effectively respond to the challenges at hand. requires an integrated response to these common While the capacity to cope with adversity may be barriers. Further work is needed to promote the universal, the specific manifestations of resilience cultural capabilities of existing services to be may vary across cultures. This may include, for responsive to diverse populations within their example, the relative importance of individual- practice. A wide range of factors influence access level (e.g., self-efficacy) versus community-level and quality of care for diverse populations, (e.g., collective efficacy) resources [62]. Other including the need for better training of providers theories of stress adaptation including the [69] and addressing the systemic factors that adaptive calibration model [63] may be applied readily contribute to health and healthcare dis- to understand how some refugee individuals are parities for underserved populations [70]. profoundly resilient in the context of extreme adversity. The capacity for resilience and adaptation—through a variety of individual, Distrust of Authority and/or Systems familial, and community resources and processes—suggests that there is much to be The experience of refugees often includes learned from those who adapt and thrive despite extreme abuse of power by those in authority. adversity. With an overemphasis on examining Systems usually designed to protect people may pathology and distress, there is a missed have come under the power of those who opportunity to understand the breadth of human perpetrated atrocities. Sharing personal experience and the range of mental health out- information with strangers, such as one’s tribal comes experienced in resettlement. affiliation or even their full name, may have 260 B. H. Ellis et al. placed one at risk of being a target of violence. mental illness may not be believed to be possible. As a result, many refugees, especially those who When a youth exhibits internalizing or external- have experienced government-sanctioned izing problems, refugee families may define the persecution and violence [71, 72], have developed problem as an issue related to success at school or an understandable distrust of authorities and culture-specific conflicts within the family or governmental systems, and this distrust may be community. A refugee or migrant individual who applied to healthcare service systems. Perception uses drugs or alcohol to cope with mental health of individuals and institutions of power is also a problems may be seen as violating religious or central issue. Due to a history of marginalization cultural expectations and subsequently be ostra- and a legacy of disempowerment in social, cized from the community. In some instances, political, and economic arenas, refugees may community members may be concerned that if an mistrust service providers who represent a more individual is known to be receiving mental health- socially empowered group [73, 74]. Experiences care, the stigma they may experience would be of distrust and alienation likely only increase as more damaging than receiving no care at all. More the experience of being a refugee comes under broadly, refugee and migrant communities may greater international scrutiny and heated hold different explanatory models for psychologi- sociopolitical discourse. Issues of power and cal problems [80, 82] and view what mental health distrust may affect services at the individual providers label as “mental illness” as problems level, challenging the development of a related to spirits, possession, or religious events therapeutic alliance, or at a programmatic and [76, 77, 83]. Overcoming such stigma requires community level, leading to low rates of thoughtful community-based dialogue with stake- engagement and high no-show rates. The holders and leaders, broad-based psychoeduca- potential legacy of distrust may require extra tion, and outreach efforts at the individual, family, time for rapport building and development of a and community level. Structural changes, such as sense of safety and security during the process of delivering services within trusted agencies like treatment [75]. Programs that build trust not just schools, resettlement agencies, community cen- with identified clients or patients but with whole ters, or places of worship, can further reduce communities may be better accepted when potential barriers associated with the stigma of services are indicated. Healthcare systems’ use of mental illness. The integration of cultural formu- community health worker models is increasingly lations into treatment and service delivery repre- widespread as there is a growing recognition of sents a critical and needed step that acknowledges the need for greater representation within the the cultural bounds of current diagnostic systems health sector and in the delivery of services. and treatments within a specific Western psychiatric model of disease. The explanatory models framework [80] provides an approach that enables Stigma of Mental Illness collaboration and discussion of the range of understandings of the etiology, course, and conse- The stigma of mental illness within many refugee quences of mental illness, including what consti- communities may serve as a considerable barrier tutes culturally appropriate steps in addressing to seeking mental health services [76, 77]. In concerns. many cultures, mental illness is considered a taboo topic and is not openly discussed [77, 78]. For some ethnic groups, there are even limited Linguistic Factors words to describe mental health or mental illness in their language [76, 79]. In some refugee com- When a person from a refugee background does munities, mental illness is not understood on a seek to engage in mental health services, the lack continuum; an individual is either “well” or of linguistically accessible and culturally respon- “crazy” [77, 80, 81]. Furthermore, recovery from sive services presents a further barrier [84]. 13 Understanding the Mental Health of Refugees: Trauma, Stress, and the Cultural Context 261

Simply put, services must be available in the lan- ongoing stressors may be important determinants guage of fluency of the patient and family in order of refugee mental health and well-being [18, 90, to be accessible. Even if a child is fluent or profi- 91]. Despite this, mental health service systems cient in English, parents may not be [85, 86]. This and refugee resettlement services are typically presents a challenge to obtaining parental consent delivered by different agencies with relatively for treatment for a child and subsequently engag- little integration and connection. Families ing the parents in the child’s treatment. Given the referred to mental health services may look to range of linguistic proficiency among refugee providers for assistance with tangible needs such children and adults—and at times the preference as food and housing and may be reluctant to for different languages between child and par- spend time and energy engaging in services (e.g., ent—services need to be flexibly available in dif- talk-based psychotherapy) that do not directly ferent languages. Changing demographics of and overtly address basic needs (e.g., completing refugee arrivals further complicates the capacity housing application paperwork). Mental health of mental health and social service organizations services that broaden the scope of care to facilitate to provide linguistically appropriate services. The addressing multiple aspects of the social ecology use of interpreters, in person or via phone or vid- that impact the individual are likely to be more eoconference, can aid in reducing this barrier. The successful in engaging refugees in mental health use of children or relatives as interpreters is treatment. If providers do not have the resources strongly discouraged. This is because children are or training to support other basic needs, it is placed in a dual role as family member and para- important to consult and/or provide “warm hand- professional and are exposed to information that offs” to other providers so that important issues may not be appropriate or effective for them to do not get overlooked (e.g., attending an initial hear in such a context. Even if a parent consents to meeting with a housing-focused social worker or such an arrangement, providers should make printing out and explaining directions to a local every effort to find another alternative and should food pantry and then calling ahead to let the be transparent about this with the family. In some organization know a family is on their way). programs, the integration of a cultural broker, or an individual trained to not only interpret the language but also interpret the culture and context of Mental Health Assessment both the refugee’s cultural group and the service system, has served to improve both linguistic Individuals with refugee backgrounds present a access and culturally responsive practice [87, 88]. number of challenges to traditional psychological assessment, including validity of conducting assessments cross-culturally, complex physical Primacy of Resettlement Stressors and psychological issues that may be present with refugee trauma and torture survivors, and the Finally, even if barriers of trust, stigma, and lan- broader social context that influences psychologi- guage are addressed, many refugee individuals cal well-being and suffering. These three assess- and families do not identify obtaining mental ment challenges are considered below. health services as a primary need. Rather, managing the resettlement stressors, such as ensuring adequate food and housing for the Cross-Cultural Validity of Mental family and securing employment, is prioritized Health Assessments [89]. These foundational needs generally need be met or at least partially stabilized before most Methodologically, many standardized mental refugees have the practical and psychological health assessment tools used in mental health resources available to focus on mental health evaluations have not been specifically developed treatment [86]. Research suggests that these or adapted for use with refugees [29, 83, 92]. 262 B. H. Ellis et al.

Instruments used with Western populations may Assessment in the Context not be available in the necessary languages and, of Complex Physical, Psychological, even when they are, may not have been adequately and Sociocultural Factors tested for construct validity and linguistic comparability. Refugees from orally based Refugees, and in particular trauma and torture cultures, in which the language is primarily survivors, often present with complex physical spoken rather than written, or who are not fully and psychological factors that may affect assess- literate in any language, may be unfamiliar with ment. As discussed in relation to treatment standard assessment formats, including engagement, past experiences of abuse or mis- commonly used Likert scales, rendering such treatment at the hands of authorities may signifi- tools much less useful. Established assessment cantly contribute to a reticence to trust and share norms or cut-off scores may be unavailable for a personal information [97]. For some, a clinical specific cultural group in question and therefore interview may be reminiscent of past trauma, as have no appropriate clinical reference point for in the case of torture survivors who underwent quantitative assessment and tracking. Whereas interrogations. Those who are seeking or have psychological assessment with any population received asylum status may also be concerned should take into account how social and cultural about whether divulging information could be identity shapes the presentation and formulation used to undermine their case and their safety. For of a mental health problem, over-medicalizing these reasons, extra time and care may be needed distress within refugee populations can be to build and establish rapport and trust so that the especially toxic and short-sighted because of the information that needs to be broached can be dis- enormous social and ecological factors that likely cussed effectively. Head trauma including previ- influence the presenting problems [93, 94]. ously undiagnosed traumatic brain injuries, When possible, instruments that have demon- occurring in the context of torture, war, or flight, strated cross-cultural acceptability and validity may further complicate assessment. Similarly, with the population of interest should be used. malnutrition or severe untreated illness histories Examples include trauma screeners such as the may also contribute to short- or long-term cogni- War Trauma Scale and the Harvard Trauma tive deficits and may heavily influence the results Questionnaire [95]. Examples of measures of psy- and recommendations of psychological assess- chological distress that have been adapted for ment [98]. Within some cultures, strong taboos refugee populations and the use of which has been or gender roles may also affect the degree to documented in the literature include the Hopkins which refugees feel comfortable sharing infor- Symptom Checklist-25, the Beck Depression mation with providers. A female survivor of Inventory, the Impact of Event Scale, and the sexual violence, for example, may be particu- Posttraumatic Symptom Scale-30. Additionally larly hesitant to share this information with a some instruments, like the Harvard Trauma male provider due to her traumatic experiences Questionnaire, have been validated in multiple as well as potential cultural stigma and shame different languages [96]. In the absence of cultur- associated with rape. Even if the clinician is ally validated instruments, scoring and interpreta- female, the presence of a male interpreter or tion of assessment tools should be done in the someone known from the community may context of other information that has been gath- impede open discussion. Awareness of gender ered and used to inform clinical judgment rather norms, cultural taboos, and sensitivity to the than determine diagnoses. For a more extensive changing dynamics when an interpreter is pres- list of measures that may be effective for use with ent are all important considerations when deter- refugee families, please visit https://www.nctsn. mining steps for culturally responsive and org/resources/refugee-standardized-measures. empathic assessment. 13 Understanding the Mental Health of Refugees: Trauma, Stress, and the Cultural Context 263

Assessment of the Broader Social migration violence and exposure to post-migration Context and Protective Resources violence. Risk factors on a family level include having a single parent, having a parent with psy- In addition to standard domains of mental health chiatric problems, having a parent who was evaluations, clinical assessment of refugees exposed to violence, having poor financial sup- should include an assessment of the pre- and port, and arriving in host country unaccompa- post-migration experiences that particularly nied. On a community level, risk factors include impact mental health outcomes (e.g., the four perceived discrimination and several changes of core stressors; see Table 13.2). Fazel et al. [32] residence in the host country. The multiplicity of discuss specific pre- and post-migration factors factors that impact a refugee’s well-being needs that put refugee youth at risk for psychological to be taken into consideration as part of a com- difficulties or mental health issues. On an indi- prehensive assessment of psychological vidual level, risk factors include exposure to pre- functioning.

Table 13.2 Four core refugee stressors Traumatic Occurs when a person experiences an intense event that threatens or causes harm to their stress emotional and physical well-being. Refugees may experience traumatic stress related to: War and persecution Torture Rape Forced displacement from home Flight and migration Poverty Starvation Family/community violence Resettlement Is related to the refugee experience as people try to make a new life for themselves in a new stress country and may include: Financial stressors Difficulties finding adequate housing Difficulties finding employment Loss of community support Lack of access to resources Transportation difficulties Loss of pre-migration status Acculturation Occurs as people try to navigate between their new cultural context and their culture of origin and stress may include: Conflicts between children and parents over new and old cultural values Concern over children “losing” their culture Conflicts related to cultural misunderstandings The necessity to translate for family members who are not fluent in English Problems trying to fit in at school Struggle to form an integrated identity including elements of their new culture and their culture of origin Isolation Is related to refugees’ experiences as ethnic and cultural minorities in a new country and may stress include: Feelings of loneliness and loss of social support network Discrimination Experiences of harassment from peers or law enforcement Experiences with others who do not trust the refugee Feelings of not “fitting in” with others 264 B. H. Ellis et al.

Mental Health Interventions tioners are increasingly incorporating approaches that acknowledge cultural differences in meaning There have been multiple reviews in the past and distress and that foster culture-specific meth- decade that detail the current evidence base in ods of coping and responding to adversity [109, refugee mental health interventions for adults 110]. There has been a growing emphasis on and/or youth [15, 21, 27, 84, 99, 100]. These interpersonal [111] and narrative expressive ther- reviews have underscored the growing publica- apy approaches [104, 112, 113], which corre- tion of refugee intervention research but also the spond well within cultures with more collectivistic limited numbers of tightly controlled trials [101]. and oral traditions. For example, in a 2007 review of PTSD-specific In working with refugee youth, the largest treatment studies by the Institute of Medicine body of evidence has been in the evaluation of (IOM), only two studies with refugees [102, 103] school-based programs [84, 107, 113, 114]. met the criteria of well-designed studies to be Many of these programs focus on the use of arts- included in the review. The challenges associated based therapies to support the expression and with conducting randomized controlled trials resolution of trauma and adjustment-related with refugee populations are significant, and concerns through a developmentally appropriate innovative research designs and methods are medium. Some adolescent refugee mental health needed to address this evidence gap [104]. programs have also focused on addressing social The vast majority of evaluated interventions and environmental challenges faced by youth, have focused on symptoms of anxiety and PTSD such as stressors related to family conflict, associated with trauma. Cognitive-behavioral unstable living conditions, and financial stressors therapy (CBT) has been the most commonly [65, 109]. In the psychological- and systems- evaluated approach and treatment trials have based intervention, Trauma Systems Therapy for largely demonstrated reductions in PTSD and Refugees, an adapted model of Trauma Systems anxiety symptoms [67, 84, 95, 102, 105, 106]. Therapy [115], school-based psychological skill- Studies have evaluated CBT with a wide range of building groups addressed acculturative stress populations such as Cambodian adults, either and basic communication and emotion regulation alone [107] or in combination with pharmaco- skills, while more intensive, individualized logical interventions [67] and in school-based trauma treatment was provided for youth with samples of youth of varying nationalities [84]. A more significant mental health needs [21]. recent systematic review and meta-analysis of 12 Programs such as this represent essential clinical trials found narrative exposure therapy, a multilayered responses that not only recognize trauma-focused variant of CBT, to have the best the importance of addressing trauma but also the empirical support for treating PTSD in refugee need to target the resettlement challenges and asylum seekers resettled in high-income commonly faced by refugee communities that are countries [108]. frequently living in low-income and under- In recent years the shift in focus from a long- resourced neighborhoods. More such programs standing emphasis on reactions to torture and are needed that support the wide-ranging trauma has researchers and practitioners question- challenges associated with forced displacement ing the cross-cultural applicability and utility of and resettlement. the traditional trauma treatment model [101, 102]. Regardless of the model of care used, knowl- Increasingly there has been more of a focus on edge of an individual’s culture and refugee expe- understanding refugees’ experiences and chal- rience will better inform care. Below, the authors lenges within the resettlement environment, have created a table of key questions and issues which is more modifiable, and in fostering that providers can consider across the provision strength, capacity, and resilience among individu- of services when working with refugee als and communities [5]. Researchers and practi- communities. 13 Understanding the Mental Health of Refugees: Trauma, Stress, and the Cultural Context 265

Key Questions and Issues session(s) is not recommended because trust has for Consideration When Working yet to be developed between the provider and with Refugees patient. Some initial understanding of many of the above questions can be gained through online • What is this patient’s country of origin? What resources that include brief summaries of the is the recent history of that country and what culture, history, refugee experience, and health led to the exodus of refugees? practices of refugee groups (e.g., Ethnomed.org; • What are the patient’s social and cultural iden- or UNHCR.org; http://www.cal.org/areas-of- tities (e.g., race, ethnicity, religious and spiri- impact/immigrant-refugee-integration). tual beliefs, gender, disability status, etc.)? Although every refugee’s experience is unique, Within their country of origin, did their par- being aware of the general sociopolitical context ticular identities and status (e.g., ethnicity, that has affected the client and their community religion/religious sect, tribe/caste) have will both communicate the clinician’s interest in unique experiences of power and/or understanding the client’s culture and also allow persecution? for a more nuanced understanding of the client’s • How did the patient come to be here? Did this particular experiences. While a provider can individual spend time in refugee camps, have never understand all the intricacies of the many a dangerous flight, and arrive as an asylum refugee cultures that may resettle in their country, seeker? Did the patient arrive with other some basic knowledge can help guide questions family members? If not, who are they in a manner that shows respect for the client and separated from and what are the circumstances a willingness and empathic openness to learn. that led to the separation? Imagine if your healthcare provider did not know • How long has this individual lived in the some of the most basic information about your USA? Has this individual migrated within the country or culture of origin—would you trust USA? them or assume that they would be knowledgeable • How is mental illness viewed in their culture? in helping you? How is psychological distress expressed? • How is healing approached in their culture? Who or how does one turn to help in their Psychopharmacology culture? Is the patient seeking help through traditional means as ascribed by their culture Psychopharmacological interventions can be of origin? effective treatments for mental health problems • What is the resettlement context for this for some refugees and may be more acceptable patient? Is there a strong, supportive ethnic than psychotherapy within some cultural groups community that the patient is or could be a where receiving a medical intervention is seen as part of? Does the patient have support for more socially acceptable than a psychotherapeutic basic resettlement needs, e.g., housing, job intervention. There is a need for more research training, language classes? evaluating different pharmacological approaches • What is the preferred language(s) of the for the treatment of refugee individuals, and this patient and what languages are spoken in their literature is even more sparse than the research on family? If needed, who will interpret for the behavioral health interventions for refugees. In a patient? Does the interpreter come from a 2017 review paper, 15 pharmacological particular ethnic, tribal, or religious intervention studies with refugees were reviewed, background that is different from the patients, but due to limited power and inconsistent study and if so how might that affect the work? designs, the authors reported that there is not yet evidence for formal psychopharmacological Asking many of these questions directly to a recommendations for treating depression and patient or family member during the first PTSD in refugee populations [116]. 266 B. H. Ellis et al.

Of the limited available psychopharmaco- Additional Cultural Considerations logical evidence, Smajkic and colleagues [114] found significant reductions in PTSD and In considering effective and appropriate mental depression symptom severity and improve- health services for refugee populations, there are ments in Global Assessment of Functioning a number of important additional cultural (GAF) scores following 6-week treatment with considerations. Culturally responsive practice sertraline (selective serotonin reuptake inhibi- with refugee and migrant communities requires a tor, SSRI, antidepressant) and paroxetine balance of cultural competence (i.e., the attitudes, (SSRI, antidepressant) in a trial with adult knowledge, and skills to appropriately and Bosnian refugees. Another treatment group was effectively work with diverse populations) and treated with venlafaxine (serotonin-norepi- cultural humility (i.e., an open, empathic, curious nephrine reuptake inhibitor, SNRI, antidepres- stance in which one can learn about others with sant) and evidenced significant reductions in the assumption that one will never be an “expert” PTSD symptom severity and improvements in in any culture) [119]. It requires recognition of GAF scores but had no changes in depression the broader systems of power, privilege, and and reported significant side effects. Otto and structural inequality [120], as well as the need for colleagues [117] found the greatest improve- organizational, structural, and clinical levels of ments in a study of Cambodian refugees were cultural responsivity and intervention [121]. those treated with combined sertraline and ten Having a basic fund of knowledge about a refugee sessions of CBT. group, such as their country of origin’s history As with other intervention approaches, it is and their reasons for fleeing [84, 88], along with important to consider how cultural attitudes and an understanding of foundational cultural norms understanding of medication may affect and traditions is important for effective practice. medication adherence for diverse refugee To do this, there are numerous resources available populations [118]. Some individuals of refugee online to learn more about the culture and country backgrounds may assume psychiatric medications of origin of individuals a clinician hopes to serve function similarly to medications such as pain [96, 122]. There is also a significant need to relievers, in that medication should be taken enhance training programs and their effectiveness when symptoms are felt and are expected to lead in preparing and upskilling practitioners in their to rapid and immediate symptom relief [117]. cross-cultural capabilities. As mental health This perspective may lead some refugees to stop providers, it is critical to understand culture- taking their medication if it does not work specific explanations of and expressions of immediately and/or stop their medication as soon mental illness and psychological suffering (e.g., as symptoms reside. Rapid self-initiated changes cultural idioms of distress), to recognize how in psychopharmacological medication dosing are they manifest within specific cultural contexts, not advised and can at times make existing and to effectively and appropriately respond to problems worse. Ongoing monitoring and such presentations. Mental health services that education around the reasons why psychiatric explicitly integrate cultural training and medication needs to be taken consistently may consultation into their practice, and models of improve medication adherence and treatment care that allow for flexible adaptation to different buy-in. In addition, possible barriers to taking cultures, contribute to providing culturally medication, such as concerns that fasting during responsive services for refugees. Ramadan prohibits medication, concerns that In addition to building representation of Western medications are addictive, or preferences diverse populations within the mental health for traditional non-pharmaceutical remedies, profession, another way to increase culturally should be reviewed in consultation with cultural responsive services is through the use of brokers. interpreter services or cultural brokering [123, 13 Understanding the Mental Health of Refugees: Trauma, Stress, and the Cultural Context 267

124]. The use of these services can facilitate It is important to provide these services when an cross-cultural communication and improve individual or family speaks English as a second quality of care in clinical settings. In some language or when there is a specific language/ settings, the use of a professional cultural broker dialect that the family wishes to receive services takes the place of an interpreter. The role of a in that the provider is not fluent in. As discussed cultural broker differs from that of an interpreter earlier, providers should avoid using children or in that in addition to providing interpretation, the other family members as interpreters, and broker also serves as a bridge, link, or mediator whenever possible use a consistent interpreter or between groups or persons of different cultural cultural broker for continuity, establishment of backgrounds for the purpose of reducing conflict trust, and building an effective working and producing effective and sustainable change partnership between broker, clinician, and [125]. Cross-cultural communication includes patient. Brokering or interpreting services is best both verbal and nonverbal communication, as delivered when the provider can set aside time well as the communication of cultural norms. prior to the session and ideally following the Cultural brokers bi-directionally interpret both session to discuss content and goals of the session the spoken words and the subtext communicated with the broker or interpreter. This discussion through nonverbal and/or culture-specificallows for mutual information sharing and communication. An example of this might be for feedback, dyadic strengthening, and effective the broker to interpret not only the spoken words treatment planning between the two professionals. of a client to a provider, “can I offer you some tea?”, but also the subtext that to refuse the drink in someone’s home would suggest distrust and Conclusions and Future Directions disrespect. A cultural broker might also later share with the clinician that offering tea is a While the nature and location of political conflict common sign of courtesy and respect and to around the world will continue to change, the refuse such a gesture, particularly as a person in a need to welcome those who have been most place of relative power is potentially offensive or affected by violence and human rights abuses insulting. remains certain. As the field of refugee mental Many more complex and multifaceted con- health research and clinical innovation moves for- cepts may require cultural broking, such as how to ward, improvements in the clinical assessment physically sit in a psychotherapy session (e.g., eye and diagnosis of refugees and forcibily displaced contact, foot placement), what experiential psy- individuals will better enable mental health pro- chological interventions (e.g., role-playing, mind- viders to effectively serve this population. Mental fulness exercises, exposure procedures, arts and health providers, educators, and policy makers crafts projects) are appropriate or inappropriate, a have an increasing opportunity to structure mental family’s perception of symptom manifestation, health services in ways that meet the complex how “talking” about problems can be effective, challenges of refugee communities. Both organi- and so on. The role of cultural brokers in a mental zational and systemic considerations, as well as health program is multifaceted; they act as an clinical approaches, can build on recent refugee essential conduit between the patient and pro- research to provide a comprehensive, integrated vider, hold and share information that facilitates response to refugee mental health needs. the relationship between patient and provider, and act as a bridge upon which the relationship between the patient and provider is built and Organizational/Systemic strengthened. There are multiple considerations for using an Increasingly, refugee mental health is being interpreter or cultural broker in a clinical setting. understood as an outgrowth of not only trauma 268 B. H. Ellis et al. but also the significant challenges faced by refu- flexibly respond to the linguistic and cultural gees in resettlement (e.g., acculturative stress, characteristics of new refugee groups. There is a social isolation and discrimination, structural significant need to improve training models and resettlement stressors). These various needs are the representation of diverse populations within not simply additive but interrelated; trauma treat- the healthcare delivery system. Attention must ment may be less effective for a refugee family also be paid to the ways in which organizational struggling with basic living insecurities, and the and structural factors may impede effective and ability to obtain employment may be especially culturally responsive care. Models such as inte- challenging for refugees struggling with mental grating cultural brokers into mental health service illness. Mental health services that are provided in systems provide a framework on how practices an integrated fashion with other resettlement, can be adapted and delivered to new groups. health, and social services may be most success- Although the specific adaptations and cultural ful in engaging, retaining, and effectively treating considerations may change with each new group, refugee and forcibly displaced communities. This the process of thoughtfully integrating cultural could be accomplished through the integration of expertise into clinical treatment, in consultation other services into mental health service systems with community stakeholders and leaders, should or by delivering mental health services through remain constant. In order to accomplish this, service systems already serving refugees (e.g., important future directions include establishing resettlement centers, community centers, schools, formal billing mechanisms so the work of cultural places of worship). The authors note that in their brokers is supported in a sustainable way, estab- intervention development and evaluation activi- lishing clearer training and professional develop- ties through the Refugee Trauma and Resilience ment guidelines for cultural brokers embedded Center at Boston Children’s Hospital, building within clinical and social service settings, and partnerships between community agencies, men- providing more formalized opportunities for mental health providers, and other service systems tal health providers to become trained in refugee such as resettlement agencies and schools has and immigrant responsive care. shown particular promise in meeting the multi- While much work remains to be done in level needs of refugees. understanding the experiences, mental health trajectories and healing of refugees and forcibly displaced communities, providers, educators, Clinical Approaches researchers, and clinicians must be prepared to serve these individuals and families in need of At a clinical level, the effective support and treat- mental health services. 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A American Psychiatric Association Conferences, 232 Acculturation, 99, 114, 130, 158, 161, 162, 168–170, American Psychological Association (APA), 239 183, 184, 214–216, 256 Amitryptiline, 187 Acculturation family distancing (AFD), 184 Anatomical dysphoria, 250 Acculturation stressors, 204 Anterior cingulate cortex (ACC) activates, 112 Acculturative stress, 161, 214–216, 221, 255, 256, 263 Anti-bullying legislation, 82 Adaptation, 99 Antidepressant, 31 Adaptive social behaviors, 258 Anti-gay bullying, 82 Adverse childhood experiences (ACEs), 108 Anti-immigrant policies, 92, 99 Age-appropriate assessment of psychosexual Anti-immigrant rhetoric, 92 development, 240 Anti-immigrant sentiment, 99 Agency for Healthcare Research and Quality (AHRQ), 60 Anti-LGBTQ bullying, prevalence of, 82 Alprazolam, 186, 187 Antipsychotic/tricyclic antidepressant, 186 Alzheimer’s disease, 119, 120 Anxiety, 109, 120, 153, 178, 179, 191, 257 American Academy of Pediatrics (AAP), 239 LGBTQ, 167–171 American identity, 65 client with active coping, 170 American Indians and Alaska Natives mental health clinical recommendations, 169 Bureau of Indian Affairs (BIA), 133 education and acculturation, 168 collecting and measuring mental health mental health services, 169 data, 139, 140 relaxation and organizational techniques, 168 counseling and psychotherapy, complexities in, 136 and panic attacks, treatment on, 245 cultural mental health practices of, 142–144 Arab Americans, mental health of delivery of services, 132 alternative cultural practice, traditional healers, 154, 155 demographic patterns, 131, 132 clinical recommendations for working epidemiological considerations, 139 with, 163, 164, 166, 167 epidemiological data, 139 cultural considerations evaluation-related considerations, 138, 139 acculturation, 161, 162 Indian Health Service (IHS), 133, 134 family, 159 native traditional healers and collaboration, 135 language, 158 prevention approaches, 140 Western psychiatric methods, 158 prevention-related considerations, 140, 141 discrimination, 162, 163 primary prevention efforts, 141, 142 gender, 159–161 program evaluation, 137 immigrants, 149 secondary prevention efforts, 142 immigration patterns to United States, 151, 152 service delivery considerations, 134, 135 LGBTQ, 167–171 service providers, characteristics of, 136, 137 mental health resources, underutilization of, 155, 156 state and local services, 132 paroxysmal episodes of body shaking, 153, 154 treatment approaches, 135, 136 PTSD, 156–158 treatment-related considerations, 137 religious considerations, 163 Tribal-Based Health Care Programs, 134 research, 152, 153 utilization of services, 137, 138 social demographics, 150, 151 American Medical Association (AMA), 239 Arab world, 149 American Psychiatric Association (APA), 168, 169, 239 Arena, 86

© Springer Nature Switzerland AG 2019 275 R. Parekh, N.-H. T. Trinh (eds.), The Massachusetts General Hospital Textbook on Diversity and Cultural Sensitivity in Mental Health, Current Clinical Psychiatry, https://doi.org/10.1007/978-3-030-20174-6 276 Index

Asian Americans Center for Disease Control and Prevention, 108, 130, 242 abuse/trauma, 193, 194 Cervical cancer, 77 acculturation and families, 183, 184 Chain migration, 92 denial, 190 Cherokee Talking Circle, 141 disparity of percentage of college graduates, 176 Cis-gender, 45 engaging in treatment, 184–186 Civil Rights, 107 family culture, 182, 183 Client-centered approach, 170 idioms of distress, 179 Clomipramine, 187 cultural concepts, 180, 181 Clozapine, 187 somatization, 179, 180 CNSDose, 210 immigration history, 176, 177 Cocaine, 244 inpatient treatment, 188, 189 Cognitive and affective processes, medical-decision intergenerational conflict, 191, 192 making, 205 large scale studies of mental health, 178 Cognitive behavioral therapy (CBT), 188, 189, 264, 266 lesbian, gay, bisexual, or transgendered, or Cognitive dissonance, 57 questioning (LGBTQ), 192 Cognitive learning, 19 mental health disorders, prevalence of, 177–179 Co-mediation, 50 mental health services, utilization of, 179 Communication patterns, 219–221 primary care physician (PCP), 196 Communication styles, 9 psychopharmacology, 186–188 Community-based initiatives, 203 psychotherapy, 188 Compounded community trauma, 204 racism and mental health, 192, 193 Confounding variables, 45, 46 religion, philosophy and health beliefs, 181, 182 Conscious bias, 8 shame, 191 Cortisol, 115 stigma, 190, 191 Counseling and psychotherapy, 145 traditional medicine and Western approaches, 189, 190 complexities in, 136 US Census information, 175, 176 outcome research, 135 Assimilation, 130 Cross cultural communication, 4, 267 Attention deficit hyperactivity disorder, 87 communication styles, 9 Atypical antipsychotics, 187 intersectionality, 10 privilege, 9, 10 racial identity development theory, 11 B segregation, 9 Banking model, 14 white fragility, 10, 11 Beck Depression Inventory, 262 Cross’ Five Step Black Identity Development Model, 11 Bent nail research, 120 Cuento therapy, 220 Benzodiazapines, 187 Cultural and diversity issues, 38, 39 Benzodiazepine diazepam, 186 cultural competence development, 46, 47 Best/wise evidence, 139 discrimination in negotiation, 40, 41 Best/wise practice, 139 diverse practitioners, field of medication, 51 Bias, definition of, 12 gender as culture, 44, 45 Bicultural Effectiveness Training model, 221 internalized oppression, 42 Biculturality, 99 mediation and problem of bias, 39, 40 Biologic and maturational processes, 234 gender differences, 39 Biologic sex, 230 mandatory mediation, 39 Biological influences, 230 mediator role, 38 Biopsychosociocultural framework, 230, 239–241 mediator’s relationship with parties, 47 Biosocial theory, 234 co-mediation, 50 Bipolar disorder, 116, 118, 191 confronting bias, 48 Black Identity Development Model, 11 power of narrative, 50 Boomer generation, 55 pre-mediation consultation, planning, and Bouffees delirantes, 111 research, 48 Bowenian models, 221 validating differences and commonalities, 48, 49 Building awareness/small group discussions, 18 values-based conflict, 49 Buproprion, 194 negotiation styles, 43, 44 Bureau of Indian Affairs (BIA), 133 psychological issues, 45 social dynamics, 45, 46 Cultural and familial values, 216 C Cultural belief system, 217 Cancer, 71, 77, 78, 108, 159, 241, 242 Cultural bias, 177, 179 Catholicism, 218 Cultural brokers, 267 CBT, see Cognitive behavioral therapy (CBT) Cultural coherence, 61 Index 277

Cultural competency, 7, 71, 111, 112, 266 privilege, 9, 10 definition, 27 racial identity development theory, 11 development, 46, 47 segregation, 9 and migration (see Migration) white fragility, 10, 11 Cultural complexity, 150 equity and inclusion Cultural curiosity, 71 healthcare settings, diversity initiatives in, 7, 8 Cultural differences, 3, 43, 45, 68, 256 United States, diversity initiatives in, 4–7 between Anglo Americans and Latinos, 215 expression, 15 Cultural diversity, 37, 59 Helms’ Six Step White Identity Development Cultural Formulation Interview (CFI), 29 Model, 11 Cultural history, 62 language, various forms of, 15 Cultural humility, 27, 204, 266 Liberatory Education, 14 Cultural identity, 19, 61, 70, 256 liberatory learning, 15 Culturally competent communications, 62, 63 lived experience, 15 Culturally-focused psychiatric (CFP) consultation microaggression, 12, 13 service, 34 post-dialogue evaluation survey, 20–21 Culturally relevant care, 129 structure and course Culturally-responsive services, 266 building awareness/small group discussions, 18 Cultural safety, 7 didactic/cognitive learning, 18 Cultural sensitivity, 7, 70, 75, 76, 79, 99, 112, 150, 153 facilitators training, 16, 17 medical care to diverse populations, 57, 58 frame setting, 17 in news reports of suicide, 84, 85 getting to know each other, 17, 18 opportunities to improve efforts in the media, 85, 86 large group reflections and intention, 18 People of African Descent (PAD) in the USA, 120 post-dialogue evaluation stage, 18, 19 Cultural syndromes of distress, 180, 181 Pre-Dialogue Needs-Assessment Stage and Culture-bound syndromes, 109–111, 180, 181 Planning, 16 Culture-centered family therapy models, 221 traditional diversity training, 15, 16 Culture-centered genograms, 221 Diversity training, 3–6, 17, 18 CYP2D6, 117, 118, 210 Domestic violence, history of, 159–161 CYP-2D6 poor metabolizer (PM) polymorphism, 210 Double-Loop Learning, 6 CYP450 enzymes, 117 Down’s syndrome, 119 Drapetomania, 106 DSM-5, 232 D Defense of Marriage Act (DOMA), 239 Depression, 26, 27, 31, 33, 68, 87, 94, 106, 108, E 118, 162, 177, 178, 181, 192, 194, 255, Eating disorders, prevalence of, 178 256, 258, 266 Educational attainment, 205 Dervish, 155 Enculturation, 183, 184 Desipramine, 187 Engagement Interview Protocol (EIP) Diagnostic and Statistical Manual of Mental Disorders, in clinical interventions, 34 5th Edition (DSM-5) criteria, 154, 232 cross-cultural studies of illness beliefs, 26, 27 Diazepam, 187 culture and illness beliefs, 26 Didactic/cognitive learning, 18 definition, 27 Discrimination, 162, 163, 244 development of, 28 Disease, definition of, 26 DSM-5 diagnoses, 35 Dissonant acculturation, 183, 184 elements of, 29 Diversity Among Latinos heartburn, patient with, 33 demographic patterns, 203 history of illness, 34, 35 living circumstances, 203 mental status examination, 35 quality of clinical care, 204 minority mental health in United States, 26 self-sustained ethnicities, 203 patients’ explanatory models (see Patients’ therapeutic alliance, 204 explanatory models) Diversity Dialogue, 3, 4, 19 patients’ illness narratives, 29 assumptions, 12 plurality of United States population, 25, 26 bias, 12 psychiatric assessment, culture in, 28, 29 Black Identity Development Model, 11 psychosocial history, 35 cognitive learning, 19 Erikson’s psychosocial theory of development, 237 concept of other, 14 Ethnic bias in clinical decision-making, 67 cross cultural communication Ethnic identity, 64 communication styles, 9 Ethnic matching, 212, 213 intersectionality, 10 Ethnicity, 10, 58, 59, 63, 111, 255 278 Index

Ethnocentrism, 64, 65 Harvard Trauma Questionnaire, 262 Evidence-based initiatives, 202 Healer through Koran, 155 Evidence-based practice, 8, 67 Health care environment and diversity, 67, 68 Evidenced-based interventions, 247 Health care planning and policy, 140 Experiential-based learning opportunities, 86 Health care services, 205 Expertise-related migration, 92 Health insurance coverage, 202 Explanatory Model Interview Catalogue (EMIC), 26–27 Helms’ Six Step White Identity Development Model, 11 Explanatory Models framework, 260 Hepatitis, 243 Extensive metabolizers (EM), 210 Heterosexuality treatment, 246, 247 Extra pyramidal symptoms (EPS), 118 Highly active antiretroviral treatments (HAART), 242 High-risk behaviors, identification and management, 247 F Hijab, 153 Familismo, 216 Hikkomori, 181 Family hierarchical balance, 212 Hispanic Community Health Study of Latinos Fatalismo, 218 (HCHS), 207 Federal Drug Administration (FDA), 209 Hispanic Health and Nutrition Examination Survey Female hysteria, 79 (HHANES), 206 Female reproductive system, 235 History of present illness, 29 Fetal Alcohol Spectrum Disorder (FASD), 110, 119, 120 Home, definition of, 95 Filial piety, 182 Homosexual Gypsy musicians, 236 Fluoxetine, 194 Homosexuality, 168, 169, 232 Fluvoxamine, 187 Hopkins Symptom Checklist-25, 262 Food insecurity, 204 Hormones, 235 Forced migration, 93, 95 HPV-associated genital and anal warts, 243 resilience and positive responses to, 259 Human immunodeficiency virus (HIV), 242, 243 Foster cultural sensitivity, 150 Hwa-Byung, 188

G I Gender and sexuality, 230 Identity construction, 221 assessment tool, 231 IDgenetix, 210 continuums, 230 Idioms of distress, 110, 115, 198 development, 234 among Asian Americans, 179 assessment, 245 cultural concepts, 180, 181 social anxiety, 246 somatization, 179, 180 fluidity, 246 substance use disorders (SUDs), 110 minorities, 234, 243, 244 Illness, definition of, 26 Gender consistency, 234 Imaginative and social/relational play, 234 Gender continuum, 230 Immigration, 7, 91, 92, 99, 106, 170 Gender development, 234–236 Arab immigration patterns to United Gender differences, 44 States, 151, 152 Gender dysphoria, 232, 249 Asian Americans, mental health in, 176, 177 Gender identity, 45, 169, 170, 234 Impact of Event Scale, 262 Gender identity disorder, 232 Implicit Association Test (IAT), 46 Gender revolution, 229 Indian Health Service (IHS), 133, 134, 140 Gender stability, 234 Indian Self-Determination Act, 134 Gender variance, 248, 249 Indigeneity, 139 GeneCept, 210 Indigenous leadership, 139 Generalized anxiety disorder (GAD), 207, 249 Indigenous leadership influence, 139 GeneSight, 210 Inpatient treatment, 188, 189 Genetic and environmental studies in Hispanics, Institute of Medicine (IOM), 56, 264 208, 209 Intermediate metabolizers (IM), 210 Global Assessment of Functioning (GAF) scores, 266 Internalized homophobia, 42, 245 Group for the Advancement of Psychiatry’s online LGBT Internalized oppression, 42 Mental Health Syllabus, 238 Intersectionality, 10, 57 Invisible minority, 150, 152 Involuntary migration, 93 H Iraqi refugees in United States, 156–158 Hajjab, 155 Islamophobia, 91 Haloperidol, 187 Isolation stress, 263 Index 279

J health disparities, 56, 57 Journalism, 76, 77, 80, 81, 86, 87 cognitive dissonance, 57 intersectionality, 57 mental health services for immigrant K population, 55 Katib, 155 negative social frames, 65–67 private health care coverage, 55 race and ethnicity, teaching implications of, 58, 59 L Medical model, 25 Language-based limitations, 205 Medicine, 231 Large group reflections and intention, 18 Mental disorders, 79 Latino characteristics, 214 Mental health care, 97 Latino children’s psychosocial maladjustment, 204 demographic shift, 201 Latinos’ economic and social circumstances, 207 Mental health disorders, 130 Latinos, inequities, 201 prevalence of, 177–179 Latinos’ parental involvement within school system, 206 Mental health Latinos with LEP, 211 disparities, 211, 212 Lesbian, gay, bisexual, transgender (LGBT), 5, 75 facility, 79 Lesbian, gay, bisexual, transgender, questioning or queer issues, 75, 81, 84, 86 (LGBTQ), 45, 76, 82, 192, 198 needs, 201 individual, 239 services, 202, 212 rights organizations, 239 and substance abuse, 243, 244 Syrian-American woman with anxiety, 167–171 systems, 208 client with active coping, 170 Mental illness, 75, 80, 81, 87, 108 clinical recommendations, 169 poverty, 204 education and acculturation, 168 risk factors, 204 mental health services, 169 stigma of, 190, 260 relaxation and organizational techniques, 168 as white privilege, 82, 83 Liberatory Education, 14 MeToo Movement, 83, 84 Liberatory learning, 15 Mexican American Prevalence and Services Survey Limited English proficiency (LEP), 205, 206 (MAPSS), 206 Lithium, 187 Microaffirmations, 13 Los Angeles Epidemiologic Catchment Area Study Microaggression, 5, 12, 13, 107, 116, 117, 193, 219 (LA-ECA), 206 Microassaults, 13 Low-income African American families, 110, 115 Microinequities, 13 Low-income Black communities, 119 Microinsults, 13, 107 Microinvalidations, 13 Migration, 91, 157 M acculturation, 99 Major depressive disorder (MDD), 26, 27, 31–33, 107, adaptation, 99 178, 195, 256 current stressors identification, 94 Maladaptive social behaviors, 258 diversity within diversity, 96 Mandatory mediation, 39 fusion, 99 Manic depressive illness (bipolar disorder), 116 home, 95 Marginalized population, 99 involuntary, 93 Mediation, definition, 37 language, 96 Medical and mental health concerns, 241 parenting, 98, 99 Medical and psychiatric illnesses, 204 pathology, 97 Medical care to diverse populations permanence and totality of, 95 adaptation, 68, 69 potential cultural differences identification, 94 awareness, 63, 64 potentially relevant recent/distant stressors continuing cultural education, 69, 70 identification, 94 cultural diversity, 59 push and pull factors, 93 culturally competent communications, 62, 63 safety, 92 cultural sensitivity and clinical practice, 57, 58 stigma, 96, 97 diversity and clinical practice, implications of, 70, 71 strength identification, 94 ethnic bias in clinical decision-making, 60 treatment planning, 94 identity theory, 61, 62 tripartite model, 93, 94 treatment dichotomy, 60, 61 understanding person, 94 ethnocentrism, 64, 65 understanding relationships, 94 health care environment and diversity, 67, 68 voluntary, 92, 93, 95 280 Index

Mindfulness approach, 63, 64 Parental avoidance of school meetings, 206 Mini clinical ethnographies, 29 Parental involvement in low-income Latino families and Minnesota Multiphasic Personality Inventory academic outcomes, 206 (MMPI), 116 Parent-Teacher Organization, 82 Minority racial identity development, 11 Paroxetine, 266 Minority stress theory, 243, 244 Patient-centered approach, 14, 62 Mirtazapine, 187 Patient-clinician relationship, 63 Moalj belKoran, 155 Patient-doctor relationship, 4 Model minority, 177, 197, 198 Patient compliance with antidepressant treatment, 210 Models of sexual minority identity development, 171 Patients’ explanatory models, 29, 30 Moderate managerial bias, 6 culturally sensitive disclosure of diagnosis, 33, 35 Modern mental health coverage and diversity in the news culturally sensitive disclosure of psychiatric media, 80–82 diagnoses, 30, 31 Money and Ehrardt’s biosocial theory, 234 accepting multiple explanatory models, 31 Mullerian inhibiting substance (MIS), 234 diagnostic labels, 31 Multiculturalism among adolescents, 208 disclosing diagnoses and treatment approaches in Multidimensional Ecosystemic Comparative stages, 32 Approach, 221 elicits patients’ beliefs, 31 Multiple identities, 245 reframing Western psychiatric concepts, 31 terminology, flexible use of, 31, 32 DSM-5 diagnoses, 30 N mental status examination, 30 Naltrexone, 142 PERCEPTS, 33–34 Narcissistic personality disorder, 45 psychosocial history, 30 Narrative expressive therapy approaches, 264 treatment negotiation, 32–35 Narrative therapy, 213, 214 People of African Descent (PAD) in USA National Association of Social Workers (NASW), 239 adverse childhood experiences, 108 National Comorbidity Study (NCS), 206 awareness, 112, 113 National Comorbidity Survey Replication Adolescent clinical skills Supplement (NCS-A), 208 assessment, 116 National Comorbidity Survey-Replication (NCS-R), 206 diagnosis, 116 National Epidemiological Survey on Alcohol and Related psychopharmacology, 117–119 Conditions (NESARC), 206 psychotherapy and support groups, 116, 117 National Institutes of Health (NIH) prevention treatment, 116 policy, 140 cultural competence, 111, 112 National Latino and Asian American Study (NLAAS), culture-bound syndromes, 110, 111 177–179, 193, 206 definition, 105 National Suicide Prevention Lifeline, 85 enhancing cultural sensitivity, 120 Nation of immigrants, 91 history, related to mental health, 106, 107 Naturalization ceremony, 99 idioms of distress, 110 Negative social frames, 65–67 knowledge, culture and context, 113 New Jim Crow phenomenon, 119 acculturation, 114 NLAAS, see National Latino and Asian American Study extended family, 113 (NLAAS) family and class, 114, 115 Normative distress and psychopathology, 244 racial socialization, 114 Nortryptiline, 187 racism, 115 religion/spirituality, 113 MDD, 107 O mental illness, 108 Observational learning, 235 paradoxical prevalence rates, factors Obsessive compulsive disorder, 87 contributing to, 109 Office of Minority Health (OMH), 60 prevention, 120 Olanzapine, 187 research, 119, 120 Organizational research, 5 utilization, 109, 110 Outline for Cultural Formulation (OCF) model, 28 Perceived discrimination, 207 Perceived U.S. social standing, 207 Personalismo, 217 P Personality disorders, 83, 181 Panic disorder without agoraphobia, 249 Pharmacogenomics, 210 Parent’s unfamiliarity, 206 Pharmacotherapy, 117 Index 281

Population-based epidemiological studies, 206 suicide rate, 257 Positive emotional expressiveness among Latinos, 219 trauma- and stress-related outcomes, 257 Post-dialogue evaluation stage, 18, 19 organizational/systemic, 267, 268 Post-migration distress, 193 psychopharmacology, 265, 266 Post-migration stress, 256 resettlement process, 254, 255 Post-migration stressors, 157 resilience and positive responses to forced Post-racial society, 115 migration, 259 Post-traumatic stress disorder (PTSD), 152, 156–158, social isolation, 255 162, 187, 188, 194, 195, 255–258, 264, 266 trauma, 255, 256 Posttraumatic Symptom Scale-30, 262 UNHCR, 253, 254 Prejudice and discrimination, 244 Religious and spiritual affiliations Pre-migration stressors, 157 and institutions, 245 President's Commission on Mental Health (PCMH), 144 Resettlement stress, 256, 259, 263 Primary care physician (PCP), 195, 196 Resettlement stressors, primacy of, 261 Priviledged Identity Exploration Model (PIE), 10 Resilience, 259 Privilege, 9, 10 Respeto, 217, 218 Psychiatric and medical comorbidities, 247 Risperidone, 187 Psychiatric community about homosexuality, 232 Psychiatric disorders, 177, 207 Psychiatric prevalence, 207 S Psychoeducation, 50, 187, 189 Schizophrenia, 85, 112, 116, 154, 191, 247, 257 Psychological distress, 257 Scholastic Aptitude Test, 42 Psychological diversity theory, 5 School-based studies, 244 Psychopharmacological nonadherence, 210 Selective serotonin re-uptake inhibitors Psychopharmacology, 117–119, 186–188, 265, 266 (SSRIs), 117, 266 Psychotherapy, 153, 188, 195, 249 Self-awareness, 63, 65 Psychotropic medications, 209, 210 Serotonin-norepinephrine reuptake inhibitor PTSD, see Post-traumatic stress disorder (PTSD) (SNRI), 266 Puerto Rico Epidemiologic Catchment Area Study Sertraline, 266 (PR-ECA), 206 Service providers, characteristics of, 136, 137 Service utilization disparities, 204 Severe depressive disorder, 31 R Sexual behavior, 237 Race, 10, 58, 59, 63, 111 Sexual development, 236–238 Racial/ethnic minority group, 204 Sexual identity, 150, 168, 170, 171, 237 Racial identity development theory, 11 Sexual orientation and gender identity, 233, 234 Racial socialization, 114 Short-term therapy, 197 Racism, 8, 11, 115, 116, 192, 193 Single loop learning teaches, 6 Reasons for Life and Reflective Processes, 142 Situational-awareness, 65 Refugees, 93, 255, 265 Social and cultural factors, 235 acculturative stress, 255, 256 Social and cultural influences, 234 barriers to care, 259 Social anxiety disorder, 195, 249 distrust of authority and/or systems, 259, 260 Social attitudes, 229 linguistic factors, 260, 261 Social identity theory, 61, 62 resettlement stressors, primacy of, 261 Social learning theory, 235 stigma of mental illness, 260 Social networks, 207 clinical approaches, 268 Societal antigay attitude internalization, 245 core stressors, 256 Socioeconomic status (SES), 204, 206, 258 cultural considerations, 266, 267 Somatization, 155, 179, 180 mental health assessment Spirituality, 218, 219 broader social context and protective Stereotype, 57, 65, 67, 69, 160, 170 resources, 263 phenomenon, 112 complex physical, psychological and socio-cultural threat, 42, 205 factors, 262 Stigma and bias, 247, 248 cross-cultural validity, 261, 262 Stress-related psychiatric illness, 257 mental health interventions, 264 Study of Latinos (SOL), 207 mental health needs Subconscious bias, 8 of child and adolescent refugees, 258 Substance abuse, 178 PTSD, 256, 257 Substance use disorders (SUD), 108, 110, 157, 202 suicide, 257 Suicidal ideation, 161, 178, 257 282 Index

Suicide, 129, 130, 142 United States Refugee Admissions Program cultural sensitivity in news reports, 84, 85 (USRAP), 151 rates, 107 Urban Indian health organizations (UIHOs), 133 refugees, 257 U.S. Department of Health and Human Services (DHHS), 133 US Public Health Service (PHS), 107 T US Refugee Admissions Program (USRAP), 158 Taijin kyofushu, 181 Talk therapy, 32, 156 Tardive dyskinesia (TD), 118 V Testosterone, 234–236, 248, 250 Venlafaxine, 194, 266 The Baltimore Sun, 78 Ventromedial prefrontal cortex (vmPFC) The Immortal Life of Henrietta Lacks, 77–79 activation, 113 The New York Times, 79, 81 Voluntary migration, 92, 93, 95 The New York Times and The Washington Post, 79 The New York World, 79, 80 Traditional healing, 154, 155 W Transformational Learning, 6 War Trauma Scale, 262 Transgender, 45 Waves of immigration, 151 Trauma, 193–195, 255–259, 264 White fragility, 10, 11 Trauma Systems Therapy, 264 White Identity Development Model, 11 Tribal-Based Health Care Programs, 134 White privilege, 82, 83 Tricyclic antidepressants, 187 World Professional Association for Transgender Tripartite model, 93, 94 Health, 248 Triple loop learning, 6 Tuberculosis, 78 Y Youth bullying, 82 U Youth Risk Behavior Surveillance System (YRBSS), Ultra-rapid metabolizers (UM), 210 208, 239 Unconscious biases, 8 Unconscious racial biases, 11 United Nations High Commissioner for Refugees Z (UNHCR), 253, 254 Zuni Life Skills Development Curriculum, 141