Knowledge, Skills and Techniques in Working With Latino and Other

Ethnic Clients

Presented By: Manuel Medina, Ph.D. ,

LCSW

Presented To:

Northern Arizona Regional Behavioral

Health Authority

Flagstaff, Arizona

October 9, 2014

TRAINING NORMS

1. Be on time2. Be respectful 3. Phones on vibrate4. Take a risk5. Be intellectually honest6. Be supportive of others7. Use I statements8. Wait till the person speaking finishes their thought

United States Ancestry

Percent

Largest Ancestries

2000

US Census

US Percent of Religious Denomination Census 2000

WHO IS IN THE ROOM Please state your name The agency you work with How long you have been with them Your position or role Your ethnicity / ancestry Who you were name after or your family’s

practice for naming members of the family What is you expectation for today’s training

What Accounts for Success

Program Level

Client Outcomes

Generic Criteria for Assessing and Evaluating Programs

Availability: Are the services geographically available?

Accessibility: Handicap, language, hours, days, holidays,

Acceptability: Are the services acceptable to the clients, culturally appropriate

Appropriateness: Are the services of the kind that will make an impact with the

population it is designed to serve;

Efficiency: Are the services and being delivered in the most cost effective

manner

Effectiveness: Outcomes; Are the program’s services and efforts resulting in client improvement in their social roles and functioning

Program Logic Model

Given Ethnic Clients’ Needs What Resources

Will Produce Outcomes

 • Acculturation Stress • Addictions• Alcohol drugs• Cope Strategies against discrimination and racism• Housing• Incomes / jobs• Interpersonal Skills • Mental Disorders• Resiliency• Self Advocacy

•Theirs•Yours•Ours

Functioning

• Reduce Regression in Functioning

•Maintain functional Level

•Improve Functional Level

How Much Effort is Required for Client Improvementsand How Responsive is The System

50% of Clients are measurably improved by the end of 8th session

75% by the end of 24 sessions (once a week) (Effectiveness of Psychotherapy: Lambert, M.J. & Bergin, A.E. Handbook of Psychotherapy and Behavior Change 4th Ed. Bergin & Garfield)

Outcomes: 52%-70% of Depressed clients had improved at one and two

years post treatment. One year after treatment 30% were sober and 30% had reduces

intake of alcohol (Psychotherapy: Lambert, M.J. & Bergin, A.E. Handbook of Psychotherapy and Behavior Change 4th Ed. Bergin & Garfield)

8%-20% of Clients will be worse off than when they started treatment (Dr. Christian Jarrett, the Psychologist Vol: 21 No. 1 January 2008)

49% failed to show for first session (2992 sample)41% of Clients failed to return after intake session (sample 2,551) At a certain agency that I am intimately familiar with our no

show rate is 40%

VARIABLE WHICH ACCOUNT FOR SUCCESSFUL OUTCOMES

40% client and extra therapeutic factors30% Therapeutic Relations15% Expectancy and placebo effects15% Techniques unique to specific

Lambert, M.J. (1992) Psychotherapy Outcomes Research: Implications for Integrative and Eclectic Therapist. In J.C. Norcross & M.J Goldfried (Eds) Handbook of Psychotherapy Integration pp94-129)

http://www.nrepp.samhsa.gov/Norcross.aspx Evidence-Based Therapy Relationships John C. Norcross, Ph.D., & Michael J. Lambert,

Ph.D.

1. The therapy relationship makes substantial and consistent contributions to patient success in all types of psychotherapy studied (for example, psychodynamic, humanistic, cognitive, behavioral, systemic).

2. The therapy relationship accounts for why clients improve (or fail to improve) as much as the particular treatment method.

3. Practice and treatment guidelines should address therapist qualities and behaviors that promote the therapy relationship.

4. Practitioners should routinely monitor patients’ responses to the therapy relationship and ongoing treatment. Such monitoring leads to increased opportunities to repair alliance ruptures, improve the relationship, modify technical strategies, and avoid premature termination (Lambert, 2010).

http://www.nrepp.samhsa.gov/Norcross.aspx Evidence-Based Therapy Relationships John C. Norcross, Ph.D., & Michael J. Lambert,

Ph.D.

5. Efforts to promulgate best practices or evidence-based practices (EBPs) without including the relationship are incomplete and potentially misleading.

6. The relationship acts in concert with treatment methods, patient characteristics, and practitioner qualities in determining effectiveness. A comprehensive understanding of effective (and ineffective) psychotherapy will consider all these determinants and their optimal combinations.

7. Adapting or tailoring the relationship to several patient characteristics (in addition to diagnosis) enhances effectiveness (as summarized in chapter 13)

What is Cultural Knowledge

Knowledge base for working with Latinos Individuals, Families and Community

1.Socio-Historical Knowledge

2.Cultural Values:

3. Acculturation / Assimilation

4.Cultural Identity

5.Trauma

6.Addictions

7.Mental Health

.

Socio-Historical Knowledge

Socio-historical Knowledge: “Racial caste in this land is more than twice as old as the nations itself. It began with the campaigns of displacement, killing, and subjugation of the native peoples by European Settles, and then expanded to the chattel of slavery of imported Africans. Because the roots of American prejudice and racism are some 250 yeas deeper than the bedrock of our constitutional ideals, it would be yet another from of hubris to believe that the legacy can be undone in a mere generation or two and the wounds healed”.

(Smelser, N.J., Wilson, W.J.,& Mitchell, F. (EDS) (2001) American Becoming: Racial Trends and their Consequences. Vol: 1. National Research Council; National Academy Press Washington, DC)

“The border crossed Us, we did not cross the border”

From: Acuña,R.F. (2014) Occupied American: A History of Chicanos (8th Ed)

Latino Socio-Psychological Knowledge

“The Border Crossed Us We did not Cross the Border”

Acuña’s Occupied America

Acculturation and Assimilation

Assimilation: Is the taking on the values and

behavioral of the other culture. For example moving from a competitive to a collaborative relational values and behavior or vice versa.

Acculturation: is the changes that result from continuous contact between two cultures and the effects it has on both cultures. It occurs at both the individual and the group level.

What is Cultural Specific Knowledge

Cultural competence - Having the capacity to function effectively as an individual

and an organization within the context of the cultural beliefs, behaviors and needs

presented by consumers and their communities

Cultural Adaptional SpheresDimensions Values Orientation

People to Nature

Mastery: our Challenge is to conquer and control Nature

Harmony: With Nature People and Nature co-exist

Subjugation: Life is determined by external Forces

People to People

Individualist: Autonomy and Self Sufficiency is Paramount

Collateral: Consult with family, friends, clan, etc. Interdependent

Lineal: Vertical leaders and followers. Authority is critical

Human Activity Modality

Doing: Being Active ad working hard is rewarded

Being In Becoming: Our purpose is life is to develop our inner selves

Being: It is enough to just be

Temporal Focus of Life

Future: The Present: Is Sacrificed for a better tomorrow

The Present:The moment is everything don’t worry about tomorrow

The Past: is important learn from history honor ancestors.

VALUE SPHERES

MIDDLE CLASS E/A

ASIANS AMERICAN

NATIVE AMERICAN

AFRICAN AMERICAN

HISPANIC AMERICAN

PEOPLE TO NATURE

MASTER OVER

HARMONY HARMONY HARMONY HARMONY

PEOPLE TO PEOPLE

INDIVIDUAL COLLARTEAL COLLATERAL COLLATERAL COLLATERAL

TIME ORIENTATION

FUTURE PAST / PRESENT

PRESENT PRESENT PAST PRESENT

MODE OF ACTIVITY

DOING DOING BEING IN BECOMING

DOING BEING IN BECOMING

NATURE OF SPECIES

GOOD AND BAD

GOOD GOOD GOOD AND BAD

GOOD

Values Preference Comparison for Euro-Americans and Ethnic Minorities

Respeto: Respect for the person, the other, Position of authority, and other life roles.

Dignidad: Conducting one self with dignity, genuineness, and the giving of respect to self and the others

Compadrazgo: Extended family and the support system and obligations that come with an interdependence of relationships

Confiansa: Trust of others to share and participate in the interdependence on each other towards a common value or norm

Compromiso: To commit oneself to someone or something, to give of oneself, one's skills, abilities, and loyalty

Responsabilidad: Responsibility, to one’s role, to one’s obligation in that role, to follow thorough on obligations to family and the group.

Value Preference Comparison for Middle Class Euro-American and Ethnic Minorities

RACIAL CULTURAL IDENTITY FORMULATION STAGES

STAGES OF IDENTITY

DELVELOPMENT MODEL

ATTITUDE TOWARDS SELF

ATTITUDES TOWARDS OTHER OF THE SAME GROUPS

ATTITUDES TON OTHERS OF DIFFERENT GROUPS

ATTITUDE TOWARDS DOMINANT GROUP

CONFORMITYConformity Group depreciation Discriminatory Group appreciation

DISSONANCE Dissonance Conflict between group depreciating and group appreciation

Conflict between dominant view of minorities

Conflict between group appreciation and depreciation

RESISTANCE& IMMERSION

Resistance e& immersion

Group appreciation Conflict between cultural ethnocentrism

Group depreciation

INTROSPECTION IntrospectionConcern with nature unequivocal appreciation

Concerns with ethnocentrism basis of judging others

Concerns with basis of group depreciation

INTEGRARTIVE AWARENESS

Integrative awareness

Group appreciation Group appreciation Selective appreciation

Relevant Variables Working with Latino Clients

Prevalence IdentityAssimilation / Acculturation Migration / ImmigrationTrauma

US born LatinoMajor Depression 14.4% 18.3%Alcohol Dep. 18% 14.2%Any Sub Abuse 29.3% 24.7%

Experiences of Trauma in Latina Children

Abused at a younger age

More likely to be abused by their fathers or other relatives

More likely to have siblings who were also abused

Reported higher levels of family conflict

Reported less maternal support.

Motivational Interviewing Principles Open Ended Questions: Asking the client to talk about

what is important to them rather than asking closed-ended questions about what is important to the health professional

Affirmations: Helping the client remind themselves of strengths and abilities that make change more possible.

Reflective Listening: Selectively calling attention to those parts of the clients experience that might be consistent with the change by demonstrating that the health professional is paying attention.

Summaries: Helping the Client notice their statement and experience that are consistent with change.

Small Group Exercise #1

Utilizing the criteria of Culture Values and Acculturation Stress

• Propose three questions that a Therapist could utilize to establish a therapeutic alliance with someone from a different cultural group

• Identity the ancestral origin group for the client and the therapist

• Which criteria did you use / selected to propose interview questions and why.

• State your three questions and present to the larger group

Selected Bibliography Alegria, M. Woo, M. (2009) Conceptual Issues in Latino Mental Health.

In F.A. Villarial et.al. (2009) Handbook of US Latino Psychology: Developmental and Community Based Perspectives. SAGE, LA, Calf.

Gerson, H. (2004) Malinchismo: Betraying one’s Own. In S. Singer & S.L. Kimble Eds. (2004) The cultural Complex: Contemporary Jungian Perspective on Psyche and Society. Routledge. NY. NY.

Gonzalez, N.A. Fabrett, F.C. & Knight, G. P. (2009) Acculturation, Enculturation, and the Psychosocial Adaptation of Latino Youth. In F.A. Villarial et.al. ( 2009) Handbook of US Latino Psychology: Developmental and Community Based Perspectives. SAGE, LA, Calf. Lambert, M.J. (2013) Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change 6th Ed. John Wiley & Sons, Inc Hoboken, NJ

Lambert, M.J. Ed. (2013) The Efficacy and Effectiveness of Psychotherapy. In M. J. Lambert. (2013) Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change 6th Ed. John Wiley & Sons, Inc Hoboken, NJ

Selected Bibliography Nava, Y. (200) It’s All in the Frijoles: 100 Famous Latinos Share Real-Life

Stories, Time- Tested Dichos, Favorite Folktales and Inspiring Words of Wisdom. Simon & Schuster. NY. NY.

Por Editorial Epoca S.A. de C.V. (2002) Refranes Y Dichos Mexicanos. Emperadores No. 185. Col. Portales. Mexico D.F. (edesa@data.net.mx)

Quintana, S.M. & Scull, N.C. (2009) Latino Ethnic Identity. In F.A. Villarreal et.al. ( 2009) Handbook of US Latino Psychology: Developmental and Community Based Perspectives. SAGE, LA, Calf.

Singer, S. & Kimbles, S.L. Eds. (2004) The cultural Complex: Contemporary Jungian Perspective on Psyche and Society. Routledge. NY. NY.

The Workgroup on Adapting Latino Services. (2008). Adaptation guidelines for serving Latino children and families affected by Trauma (1st ed.). San Diego, CA: Chadwick Center for Children and Families.

Umaña-Taylor, A.J. & Alfaro, G.P. (2009) Acculturative Stress and Adaptation. In F.A. Villarial et.al. ( 2009) Handbook of US Latino Psychology: Developmental and Community Based Perspectives. SAGE, LA, Calf.

Villarruel, F.A. Carlo, G. Grau, J.M. Azmitia, M. Cabreta, N.J. & Chahin, T.J.( 2009) Handbook of US Latino Psychology: Developmental and Community Based Perspectives. SAGE, LA, Calf.

Zoja, L. (2004) Trauma and Abuse: The Development of Cultural Complex in the History of Latin America. In S. Singer & S.L. Kimble Eds. (2004) The cultural Complex: Contemporary Jungian Perspective on Psyche and Society. Routledge. NY. NY.