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.