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ImmigrantsRefugees and mental health in Louisville

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Title: ImmigrantsRefugees and mental health in Louisville

1
Evidence Based Practice

Immigrants/Refugees and mental health in
Louisville

2
Description of the Problem

Immigrants and refugees are not receiving
adequate mental health care due to numerous
reasons
-Geography
-Lack of previous cultural, ethnic diversity in
state
-Most refugees arriving in Kentucky have been
living in refugee camps for decades (survival
mode, instinctual)
Consequences of our current system
-non-diagnosis/treatment of mental illness
-further installation of isolation/fear
-lack of knowledge about mental health
system/social services
Kentucky is one of the nations top ten states
with the fastest growing foreign-born population
(Migration Policy Institute, 2007)
Louisville has three agencies which are a part
of the largest privatized refugee resettlement
agencies in the country (Abner, 2005)
- Catholic Charities
- Kentucky Refugee Ministries
-Jewish Family and Vocational Service
(louisville.ky.gov)

3
Mental Health Policies and Procedures

Mental health screenings are not required by
resettlement agencies
(C. Young personal communication, October 29,
2007)
-Is this population getting diagnosed and
treated?
Title VI requires all agencies receiving federal
funds to provide information in a language
understandable by patients (Bryan 2007 Executive
Order 13166, 2000)
-How well is Title VI being implemented in
Louisville?

4
Evidence Based Practice

Conscientious, explicit and judicious use of
current best evidence in making decisions about
the care of individuals clients (Sackett,
Richardson, Rosenberg Haynes, 1997 cited in
Gibbs Gambrill, 2002)
Four Cornerstones of EBP
-Research and theory
-Practice wisdom
-Professional values
- Client preference and opinion (Gilgun, 2005)
Five Steps of EBP
- Convert needs into answerable question
- Critically appraise the evidence for its
validity and usefulness
- Applying the results of this appraisal to
policy/practice decisions
- Evaluate outcomes (Gibbs Gambrill, 2002)

5
Best Practices Inquiry

COPES Question
Client
Oriented
Practical
Evidence
Search
What are the special needs of immigrants/refugees
within the mental health system and what are
implications for providers based on these needs?

6
Methodology

Interviewed 5 Stakeholders in Louisville
concerned with mental health delivery to the
immigrant and refugee population
Edgardo Mansilla- Director, Americana Community
Center
Carol Young- Director, Kentucky Refugee
Ministries
Christy Elliott-Gonzalez, Nurse Practitioner,
Americana Health Center
Susan Rhema, LCSW, Contract worker for Seven
Counties
Mari Mujica, President, Diversity Consultants
LLC
Appraised over 20 academic articles for
literature review
-Emphasis on generalizability, trustworthiness,
and validity of results
Supplemented Consumer Interviews due to lack of
relationship and stigma associated with this
topic, with 5 qualitative articles summarizing
this populations experience with the mental
health system.

7
Results
8
Literature Review

Qualitative

Quantitative

Belief that only a higher power, (i.e. God, can
heal)
Different perceptions in the causes of mental
illness
Belief that Western doctors have an over-reliance
on prescription medication and display a
dismissive attitude
Stigma associated with illnesses
Knowing where to seek help
Discrimination
Costs of services
Language barriers

Lack of collaboration amongst providers
Pre-occupation with post-migration stressors
including housing/income and immigration status
Lack of transportation
Language barriers
Costs of services

9
Consumer Wisdom(Gong-Guy et al, (1991), Whitley
et al, (2006), Palmer (2006), Wynaden et al,
(2005) Bernstein (2007).

Primary Themes

Secondary Themes

Lack of cultural competence by provider
-insensitivity, lack of knowledge about culture
and treatment preferences
Alternative coping mechanisms
-rely on family, religion, church and self to
persevere through hard times
Different perceptions in the causes of mental
illness
Somatic Complaints vs. Mental Problems
-physical expression vs. emotional or
psychological
Need for outreach programs
Language barriers
Lack of Trust
Difference in cultural norms
Stigma
Gender differences

Depression
Difficulty seeking help
-are unfamiliar with system and how to access
help, where to go, etc.
Family Reputation/Confidentiality
-do not wish to shame family with illness
Hiding Up/Isolation-wait until the last minute
to receive care
-Might explain why many immigrants and refugees
end up in ICU in Louisville hospitals

10
Stakeholder InterviewsE. Mansilla, C.
Gonzalez, C. Young, M. Mujica S. Rhema,
Personal Communication October-November, 2007

Primary Themes

Secondary Themes

Differences in the perceptions of mental health
(i.e. causes treatment)
Lack of cultural competence by provider
Language barriers
Lack of Trust/Confidentiality towards providers
and system
Stigma
PTSD

Assimilation issues
Cost of obtaining services
Difference in cultural norms
Lack of culturally appropriate treatment
Lack of knowledge about system

11
Difference in Perceptions of Mental Health

Refugee/immigrants may not conform to our
understanding of physical or mental health, and
therefore, they define their sickness in other
ways that are culturally appropriate.
Mental health is a Western concept that is a
social construction.
Other refugee and immigrant populations may tend
to have
No concept of mental health
Express themselves physically rather than
mentally/emotionally
Not understand the importance of mental health in
our culture.
As a result, stigma associated with mental health
increases since it is a foreign idea that remains
unfamiliar amongst numerous cultures.

12
Stakeholder Interviews.contd

Need for Culturally Appropriate Treatment

Language Barriers

Many refugees believe that many American doctors
are over-reliant on pharmaceuticals
Unfriendly and hurried
Refugees/Immigrants may believe in different
causes of mental illness (i.e. Gods will, curse,
kharma, etc.)
Mental health only accepts Western values and our
pre-existing cultural ideas
Based on these facts, many will not want a
prescription, understand the diagnosis of their
illness, disagree with doctors as to why they are
or are not sick, etc.

Title VI is not being implemented in Louisville
Many refugees are being asked to bring an
interpreter/translator with them to see health
providers
Children are being used to fill these positions.
Some languages (Maay )are only spoken languages
which magnifies hardship
Interpreters/Translators are also not necessarily
able to interpret body language/appearance, etc.

13
Implications for Social Work Practice

Incorporate mental health screenings into
existing health exams administered by
resettlement agencies
-Lessens stigma
-Economically sustainable
-Routine measure
Create Culturally Appropriate /Meaningful
Treatment Plans
-Combination of both Western and Native
values/preferences, client driven treatment
-Hire or take in volunteers who practice mental
health in other countries, applicable to
Louisvilles demographics, to aid our health care
providers
-Refer clients to appropriate treatment,
acupuncture, church services, local community
leaders/healers
Mandate Continuous Cultural Competency Training
for Health Professionals
-Once is never enough
-Life-long learning/world view
-Requires deep respect of all cultures and a
desire to learn
Improve Language Services
- Hire bi-lingual leaders within different
cultural communities
-Support local council-members to implement
Title VI as a city ordinance

14
References

Abner, C. (June/July 2005). Finding Refuge.
State News. The Council of State Governments.
Available at http//www.csg.org/pubs/documents/sn0
507FindingRefuge.pdf.
Bryan, Jenessa. (2007). Voices from the
Bluegrass A Portrait of Kentuckys Children in
Immigrant Families. Kentucky Youth Advocates.
Executive Order 13166 (August 2000) requiring all
federally funded recipients to provide language
access and ensure persons with limited English
Proficiency can meaningfully access those
services. Available at http//www.frwebgate.access
.gpo.gov/cgibin/getdoc.cgi?dbname2000_registerdo
cid-fr16au00-137.pdf.
Gilgun, J.F. (2005). The four cornerstones of
evidence based practice in social work. Research
on Social Work Practice, 15 (1), 52-61.
Migration Policy Institute (2007). Kentucky
factsheet on the foreign born Demographic and
social characteristics. Available at
www.migrationinformation.org/datahub/state.cfm?ID
KY.
Sackett, Richardson, Rosenberg Haynes. (1997).
Cited in Gibbs, L., E. Gambrill (2003).
Evidence based practice Counterarguments to
objections. Research on Social Work Practice, 12
(3), 452-476.