206 -Culturally Responsive Services with Hispanic Patients
Counselor Toolbox

 
 
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Improving Cultural Competence
Working with Latino/Latina Persons
Instructor: Dr. Dawn-Elise Snipes, PhD
Executive Director: AllCEUs.com, Counselor Education and Training
Podcast Host: Counselor Toolbox & Happiness Isn’t Brain Surgery

Objectives
A Framework
~ The ecological systems approach provides a structure for understanding the importance of cultural adaptation in social work practice.
~ Macro Level: Culture frames the norms, values, and behaviors that operate on every other level
~ Micro Level represents the individual beliefs and behaviors
~ Mezzo Level represents family customs and communication patterns
~ Exo Level is how that individual perceives and interacts with the larger structures such as the school system or local law enforcement
~ the relationships between individuals, institutions, and the larger cultural context within the ecological framework are bidirectional, creating a dynamic and rapidly evolving system
Communication
~ Reading and writing are NOT a common means of communication among those from lower SES
~ Verbal and nonverbal communications from Hispanics usually are characterized by respeto (respect)
~ There is an element of formality in Hispanic interactions, especially when older persons are involved: –
~ Overfamiliarity is NOT appreciated in early relationships.
~ Direct eye contact is less. –
~ It is uncommon for Hispanics to be aggressive or assertive in health care interactions, they usually respond is silence and noncompliance.
Communication
~ Early attention must be given to building rapport.
~ Rapport begins through exchange of pleasantries before beginning assessment or treatment for the day
~ Personalismo (politeness and courtesy)is essential
~ Unconditional recognition of the essential value of each individual
~ Confianza: Being “trustworthy” based largely on personal relationships and rapport, the idea that a person “knows us” or “is one of us” far outweighs that person’s credentials or professional accomplishments
~ Hispanics expect health care personnel to be warm and personal and express a strong need to be treated with dignity.
Communication
~ Building confianza
~ Take the time to get to know them as individuals – and don’t underestimate the importance of family to one’s individual identity in Latino culture.
~ If Spanish is their primary language, make an effort to communicate with them in Spanish to some degree.
~ Older person should be addressed by their last name.
~ Avoid gesturing, some may have adverse connotations.
~ Encourage the patient to ask questions.
Cultural Beliefs
~ Latinos are an ethnic rather than a racial group; Latinos can be of any race.
~ Mexican Americans are the largest group (63 percent), followed by Central and South Americans (13.4 percent), Puerto Ricans (9.2 percent), and Cubans (3.5 percent)
Religion
~ Many Latinos place great importance on the practice of Roman Catholicism.
~ Central tenets of Latino Catholicism are sacrifice, charity, and forgiveness.
~ These beliefs can hinder assertiveness, but they can also be a source of strength and recovery
~ Along with Catholicism the use of magicoreligious is common: – Candles with pictures of saints
~ People’s relationship with church is changing
~ Protestant evangelical churches role is increasing

Cultural Values
~ Latinos can face somewhat different triggers for relapse relating to acculturative stress or the need to uphold particular cultural values
~ Personalismo is the use of positive personal qualities to accomplish a task.
~ Machismo is the traditional sense of responsibility Latino men feel for the welfare and protection of their families
~ La familia is the collective identity
~ Protective factors: family warmth, such as spontaneous expressions of concern, interest, understanding, and positive regard, as coded from recorded family interviews, appears to serve as a buffer
~ Jerarquismo: Respect for hierarchy.
Values
~ Cont…
~ Presentismo: Emphasis on present.
~ Espiritismo: Belief that good / evil spirits can affect well being and spirit of the dead person.
~ Respeto: Consideration and deference
~ Agreeableness
~ Simpatía: accord, agreement and harmony in relationships, marriage, the family and society.

Cultural Beliefs About Health and Illness
~ Collectivistic
~ The Latino paradox
~ Hispanic and Latino Americans tend to have health outcomes that “paradoxically” are comparable to, or in some cases better than, those of their U.S. non-Hispanic White counterparts, even though Hispanics have lower average income and education
~ Caregiving ideology of Latino culture exemplified by most Latino clients living with their families
~ Fatalistic views are shared by many Hispanic patients who view illness as God’s will or divine punishment brought about by previous or current sinful behavior
~ Latinos were less likely to use medical alternatives than were white Americans
~ Some Hispanic patients may prefer to use home remedies and may consult a folk healer, known as a curandero.

Definitions of Illness
~ Physical or mental illness may be attributed to an imbalance between the person and the environment.
~ Influences include emotional, spiritual, and social state, as well as physical factors such as humoral imbalance expressed as too much “hot” or “cold”
~ “Hot” and “cold” are intrinsic properties of various substances and conditions, and there are sometimes differences of opinion about what is “hot,” what is “cold.
~ “Cold“ mental health diseases/conditions include depression
~ “Hot” mental health diseases include anxiety and mania
~ “Cold” conditions are treated with “hot” medications and “hot” with “cold” medications, thus bringing the individual back into balance.
Cultural Beliefs About Addiction
~ Latinos are more likely to believe
~ Alcohol and illicit and prescription drugs will have negative consequences than are White Americans
~ Although, Puerto Rican participants were more likely than other students to see increased sociability as a positive expectancy related to drinking; yet Puerto Rican participants were also significantly more likely to report abstinence from alcohol
~ Individuals who abuse substances cause their whole families to suffer (81.4 percent)
~ people who use illicit drugs will participate in violent crime and act violently toward family members (78.9 percent).
~ Driving under the influence of alcohol is one of the most serious substance use problems in the Latino community
Cultural Beliefs About Addiction
~ Drinking alcohol is a part of social occasions and celebrations.
~ Solitary drinking is discouraged and seen as deviant.
~ Social norms for Latinas are often quite different. They are perceived as promiscuous or delinquent in meeting their family duties because of their substance use
~ Heavy emphasis on the idealization of motherhood contributes to the level of denial about the prevalence of substance use among Latinas.
Culture Bound Syndromes
~ Mal de Ojo: It is caused by a person with a “strong eye” (especially green or blue) looking with admiration or jealousy at another person.
~ Nerviosimo “sickness of the nerves” is common and may be treated medicinally or spiritually
~ Susto fright resulting in “soul loss” Susto may be acute or chronic and includes a variety of vague complaints. Women are are affected more than men.
Heirarchy of Interventions
~ Home Remedies – Relatives / Neighbors (especially females)
~ Yerbatero (Herbalist)
~ Sobador (massage therapist)
~ Partera (midwife who may also treat children)
~ Curandero Total (lay healer– physical / spiritual)
~ Doctor Naturalista – prescribe natural remedies without spiritual component.
Barriers
~ Barriers to treatment entry for Latinos include
~ Lack of Spanish-speaking service providers
~ Limited English proficiency
~ Financial constraints
~ Many Latinos only seek medical care for serious illnesses
~ Lack of culturally responsive services
~ Fears about immigration status and losing custody of children while in treatment
~ Negative attitudes toward providers
~ Discrimination
~ Lack of knowledge about available services can be a major obstacle to seeking services
Cultural Disparities
~ Mental health quality of life (MHQOL) among lesbian, gay, and bisexual (LGB) midlife and older adults was significantly lower compared to non-Hispanic Whites.
~ The association between ethnicity/race and MHQOL was explained by
~ Higher levels of perceived stress related to lower SES,
~ Higher frequency of lifetime discrimination
~ Lack of social connectedness among hispanic LGB adults.
Key Psychosocial Risk Factors
~ Increased time in the U.S
~ Higher rates of depression and anxiety with longer exposure to the U.S among Puerto Ricans, Cubans, Dominicans, and other Hispanics/Latinos; but not among other Central Americans
~ Perceived discrimination increased with duration of US residence
~ Size of close social networks shrank as time in the US increased
Key Psychosocial Risk Factors
~ Acculturation
~ Retention of cultural heritage is positively associated with self-esteem and prosocial behavior, and negatively associated with internalizing symptoms
~ Biculturalism – which involves both retaining one’s cultural heritage and acquiring the receiving culture – is even more facilitative of positive mental health and protective against internalizing symptoms
Protective Factors
~ The role of spirituality and religiousness
~ Nonjudgmental cultural attributions that convey interpersonal warmth
~ Cross-border resources.
~ Familism (Identity, pride, loyalty)
~ Familism, the valuing of family considerations over individual or community needs
~ The nuclear family is the most basic and common social unit, but many extended families also present.
~ Family involvement in health care is common and health care providers are strongly advised to encourage such involvement

Protective Factors
~ Familism
~ The Hispanic/Latino family structure tends to be patriarchal and follow a rigid hierarchical structure
~ Machismo: The father or oldest male holds the greatest power in most families and may make health decisions for the family.
~ Men are expected to provide for and be in charge of their families.
~ Marianismo: The woman is the primary force holding the family and home together through work and cultural wisdom, and responsible for most parenting.
~ Women are expected to respect and submit to their husbands.
~ Privately, some women will hold a greater degree of power.
Protective Factors
~ Perceived U.S. social standing improved with years in the U.S. and was associated with lower odds of mental health problems
~ Ethnic Identity: Belonging, pride
Approach Components
~ Use personalismo expressions of concern, interest in clients' families, and personal warmth
~ Value of the most positive aspects of Latino cultural groups: strength, perseverance, flexibility, and an ability to survive
~ Latino cultural groups view time as more flexible and less structured
~ Avoid framing noncompliance in Latino clients as resistance or anger.
~ It is often, instead, a pelea nonga (relaxed fight) showing both a sense of being misunderstood and respeto (respect that also encompasses a sense of duty) for the counselor's authority
~ Respecting women's choices can mean supporting empowerment to pursue new roles and make new choices, or reinvigorating the positivity of Latina culture to promote recovery while respecting and maintaining traditional family roles for women
Approaches
~ CBT for Latinos in mental health and substance abuse treatment settings because it is action oriented, problem focused, and didactic
~ CBT's didactic component can frame therapy as an educational (and hence less shameful) experience.
~ Contingency management
~ Motivational interviewing
~ Node-link mapping
~ visual representation using information diagrams, fill-in-the blank graphic tools, and client-generated diagrams or visual maps
~ Family-based approaches that focus on conserving and cultivating Latino cultural resources rather than on reducing family conflict
Approaches
~ La CLAve is a conceptually informed psychoeducational tool with a developing empirical base aimed at helping Spanish-speaking Latinos with serious mental illness obtain care in a timely manner. (http://www.uselaclave.com)

Cultural Assessment
~ Learn about each family member's view about their cultural background, history of the relative's illness, coping strategies, goals, and expectations of treatment, needs, and desires of family members.
~ Psychoeducation
~ Focuses on increasing illness knowledge and problem-solving skills
~ Consists of educational content on the etiology, biology, symptoms, and treatment of the problem and coping skills guidelines.
~ Each session allows for an initial engagement period, the structured didactic curricula, and an interactive period to process learned material.
~ Involves families in the skills training enterprise
~ Goals encourage the interdependence of clients with their relatives in lifestyles that enable the clients to be more functional members of the family household
Helpful Questions in Assessment
~ What do you think caused your problem?
~ Do you have an explanation for why it started when it did?
~ What does your sickness do to you; how does it work?
~ How severe is your sickness? How long do you expect it to last?
~ What problems has your sickness caused you?
~ What do you fear about your sickness?
~ What kind of treatment do you think you should receive?
~ What are the most important results for you to receive from this treatment?
Programmatic Strategies
~ Socializing the client to treatment: Latino clients are likely to benefit from orientation sessions that review treatment and counseling processes, introduce staff
~ Reassurance of confidentiality: Many Latinos, especially undocumented workers or recent immigrants, are fearful of being deported
~ Client–counselor matching based on gender: Client–counselor matching based on gender alone appears to have an effect on improving engagement
~ Client–program matching: Matching clients to ethnicity-specific programs appears to improve outcomes for Latinos.
Summary/Advice to Counselors
~ Provide bilingual services.
~ Use family therapy as a primary method of treatment.
~ Assess cultural identity and acculturation level for each family member.
~ Determine the family's level of belief in traditional and complementary healing practices; integrate these as appropriate.
~ Discuss the family's beliefs, history, and experiences with standard American behavioral health services.
~ Explore migration and immigration experiences, if appropriate.
~ Provide additional respect to the father or father figure in the family.
Summary/Advice to Counselors
~ Interview family members or groups of family members (e.g., children) separately to allow them to voice concerns.
~ Generate solutions with the family. Do not force changes in family relationships.
~ Provide specific, concrete suggestions for change that can be quickly implemented.
~ Focus on engaging the family in the first session using warmth and personalismo
~ Group leaders should allow members to learn from each other and resist functioning as a content expert or a representative of the rules of the system. Otherwise, members could see group therapy as oppressive