Working with Special Populations and Cultural Proficiency

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Working with Special Populations and Cultural Proficiency
The HIV Mental Health
Training Project
Columbia University
Working with
Special Populations
& Cultural
Proficiency
Milton L. Wainberg, M.D.
Assistant Clinical Professor
Psychiatry
Working with Special Populations
in HIV Epidemic
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Racial & Ethnic Minorities
Women
Substance Users
Gay/Lesbian/Bisexual/Transgender
Adolescents
• Female
• MSM
Creating Stable Change
Transtheoretical Model
Precontemplation
Contemplation
Preparation
Action
Maintenance
Relapse & Recycle
THIS APPLIES TO BOTH OUR CLIENTS AND OURSELVES
First…
A couple of exercises…
Close your eyes
Close your eyes again
 A walk across
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Incorporating Culture into
Health
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Individual patient-provider & system levels
Culture influences help seeking behaviors and
attitudes toward health care provider.
• My own experience: 2 Latina patients
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Communication must be clear.
Patients have personal experiences of biases
within health care systems.
Health care providers from culturally and
linguistically
diverse
groups
are
underrepresented in the current service delivery
system.
From Cultural Destructiveness
to Cultural Proficiency
Georgetown University’s Child Development Center
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Six-part continuum: destructiveness, incapacity,
blindness, pre-competence, competence, and
proficiency.
Cultural Destructiveness:
• people’s trust has been betrayed by neglecting
to fully inform them of medical risks and
benefits.
• A 1989-1991 CDC, Kaiser Permanente, and LA
County Department of Health Services measles
vaccine study. Parents were never informed that
one to the vaccines used was an experimental
vaccine and not licensed for sale in the US
Not too Good…

Cultural Incapacity:
• agencies do not intentionally seek to be
culturally destructive but rather have no
capacity to help clients from other cultures.

Cultural Blindness:
• the predominant system - express philosophy
of being unbiased: “belief that color or culture
makes no difference and that all people are the
same.”
• Making services so ethnocentric as to render
them useless to all but the most assimilated
people from other cultures.
Middle Range…

Cultural Pre-Competence:
• Hiring staff that reflects a different culture
• Exploring
how
to
reach
underserved
populations
• Offering training for their workers on cultural
sensitivity
• Conducting needs assessments concerning
racial and ethnic communities
• Recruiting diverse individuals for their boards
of directors or advisory committees
Slightly Better…

Culturally Competent:
• Respect for difference
• Continuing self-assessment regarding culture
• Continuous expansion of cultural knowledge and
resources
• Adaptations of service models to meet the needs of
different groups
• Groups have subgroups, each with important cultural
characteristics.
• Hire unbiased employees
• Seek advice/consultation from clients.
• Seek staff who represent the communities being
served and who are committed to their community
• Provide support for staff - comfortable working in
cross-cultural situations.
• Policies must enhance services to a diverse clientele.
Cultural Proficiency
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Holding culture in high esteem - more than provide
unbiased care.
Value the positive role culture can play in a person’s
health and well-being.
Add to the knowledge by:
• conducting original research,
• developing new therapeutic approaches based on
culture, and
• publishing and disseminating the results of their
research and demonstration projects.
Advocate for cultural proficiency throughout the health
care system and for improved relations between
cultures throughout society.
Role models (institutional and patient-provider level)
close cultural gaps and improve service delivery (even
provider and patient don’t speak the same language)
Attitudes …

Negative Levels:
• Repulsion
• Pity
• Tolerance
• Acceptance
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Positive Levels:
• Support
• Admiration
• Appreciation
• Nurturance
Mental Health Consequences
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Depression
Anxiety
Suicidality
Internalized Self-Hatred
Low Self-Esteem
Substance Abuse
Associations Between Health Risk Behaviors and
Self-report of Lesbian, Gay, or Bisexual (LGB)
Orientation (adapted from Garofalo et al., 1998)
Behavior
LGB%
Weapon carrying (30 days)
Gun carrying (30 days)
Weapon in school (30 days)
Smoked cigarette (<age 13)
Smoked cigarette (30 days)
Smoked at school (30 days)
Smokeless tobacco (30 days)
Alcohol use (<age 13)
Alcohol use (life)
Alcohol use (30 days)
Binge drinking (30 days)
Alcohol use at school (30 days)
Marijuana use (life)
Marijuana use (30 days)
Marijuana at school (30 days)
46.3
24.7
25.3
47.9
59.3
37.4
33.7
59.1
86.8
89.4
46.2
25.0
68.5
53.7
31.6
non-LGB%
19.8
4.9
8.9
23.4
35.2
18.4
7.7
30.4
79.0
52.8
33.0
6.2
47.4
31.4
10.7
“Although… gay, lesbian, and
bisexual youth (do) show
statistically significant
elevations in present
suicidality, depression, and
hopelessness, these
differences appear to (be)
consequential to the effects of
stress, social support, and
coping through acceptance”
(Safren & Heimberg, 1999).
Ethnic Minority Gay Youth Issues
(Ryan & Futterman, 1998)
Visible
Invisible
Ethnic
Minority
Heterosex
ual
Ethnic
Minority
GLB
Racism
X
X
Sexism
X
X
X
X
Discrimination
X
X
X
X
Violence
X
X
X
X
Potential
Rejection
X
X
X
X
Internalized
Homophobia
X
X
X
X
X
X
Experiences
Stress from
Hiding
Non-Ethnic
Minority
GLB
Closeted
Ethnic
GLB
Closeted
NonEthnic
GLB
X
X
Case Study: Interviewing…
Adam: “Doc, I’ve been messing around wt Steve”
Doc: “What does that mean?”
A: “We have been having sex”
D: “Are you enjoying it?”
A: “Sort of, yeah!”
D: “Great. What about condoms? Are you guys
using them”
A: “ Sometimes…”
D: “So, sometimes you use them, that is good, but
sometimes it is hard to use them. Let’s figure out
what helps you use them and what stands in the
way of using them. Let’s do that as you show me
how you would use this condom using this plastic
penis…
Day to Day work…
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Get to know all your patients, each as an
individual, understand them – feel free to ask!
Know your role
“None of your business!” (religion, sexuality, etc.)
Adjust to them, not the other way around – if
uncomfortable, get supervision
We all have experience prejudices – connect with
that
Work on your own prejudices – we all have them
However, not over identify – at times the
medicine can be worst than the disease!

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