Evidence-Based Practices: Shaping Mental Health Services Toward Recovery

Statement on Cultural Competence

Case studies of cultural competence

Vignette 1—Co-Occurring Disorders

Kevin is a 40 year-old African-American homeless man in Chicago who, for a decade, has cycled between jail, street, and shelter. At the shelter, he refuses getting help for what the staff believe is a longstanding combination of untreated schizophrenia and alcoholism. He becomes so drunk one night that he walks in front of a car and becomes seriously injured. While in the hospital, he is treated for his injuries, as well as placed on anti-psychotic medications after the psychiatrists diagnose him with schizophrenia.

At the time of hospital discharge, Kevin is referred to an outpatient program for individuals with dual diagnoses. Realizing that Kevin needs aggressive treatment to avoid re-spiraling into homelessness, the head of the treatment team recommends concurrent treatment of the alcoholism and the schizophrenia. The team leader is an African American psychiatrist who has an appreciation for the years of alienation, discrimination, and victimization that Kevin describes as having contributed to his dual disorders. The clinician works hard to develop a trusting relationship. He works with the treatment team to ensure that, in addition to mental health and drug abuse treatment, Kevin receives social skills training and a safe place to live. When Kevin is well enough, and while he continues to receive group counseling for his dual disorders, one of his first steps toward recovery is to reconnect with his elderly mother who had not heard from him in ten years.

Vignette 2— Assertive Community Treatment

A minister in Baltimore contacts the city’s ACT Program with an unusual concern: one of his congregants disclosed to him that another member of the congregation, an older woman from Jamaica, was beating her adult daughter for "acting crazy all the time.” The Jamaican mother may even be locking her adult daughter in the basement, according to the congregant.

One year before, the ACT team’s social worker had reached out to local ministers to tell them about the program. The ACT team had realized that better communication and referrals were needed. Stronger connections across organizations would improve chances for recovery by enhancing social support and adherence to treatment. Some of the consumers believed that treatment was counter to their religion.

The ACT social worker managed to obtain a court order to allow authorities to enter the Jamaican mother’s home. They discovered the traumatized 25-year old daughter locked in the basement, actively psychotic, and bearing marks of physical abuse. The ACT team diagnosed the daughter with schizophrenia and managed to find a group home for her. The team arranged for an intense combination of medications, individual and group therapy, including trauma care and social skills training. Through links to the church and the community, the ACT social worker helped the daughter to get clothing and spiritual support. The social worker discovered that the mother’s ethnic group from Jamaica believed that her daughter’s craziness was a sign of possession by the devil?the belief system behind her abuse. After all criminal charges were dropped, the social worker reached out to the mother to educate her about schizophrenia and to set the stage for the daughter’s eventual return to her mother’s household.

Vignette 3—Supported Employment

Jing is a bilingual vocational worker at a mental health program in San Francisco. By informally surveying her caseload, she estimates that about 30 percent of her clients are Asian. But they come from vastly different backgrounds, ranging from Taiwan to Cambodia, with vastly different educational backgrounds. One of her clients with bipolar disorder is a recent immigrant from China. He has a high school education, but speaks Mandarin and very little English. Fluent in Mandarin, Jing is able to conduct a careful assessment of the client’s job skills and a rapid, individualized job search. Because Jing is part of the treatment team, she’s aware that the client has progressed to the point of being ready for full-time employment.

Jing identifies several import-export businesses in the area with monolingual Mandarin-speaking employees. She secures a position, but it pays less than one the client would qualify for if he spoke English. Jing succeeds in persuading the client to take the position while at the same time recommending a quick-immersion night program in English as a Second Language. Jing provides follow-along job support during the next few months. When the client’s English is better, Jing searches for and manages to find a higher paying job for him. She stays in touch to be sure he can adjust to the greater demands of the new position, while continuing to receive treatment for his bipolar disorder.

Vignette 4— Medication Management

A primary care doctor at a rural Indian Health Service clinic tentatively diagnoses John, a 65-year old American Indian man, with a severe depression. But he is unsure whether he might have bipolar disorder. John had relied on a native healer for years but he had become so debilitated and despondent in recent weeks that his family drove him on the 4-hour trip to the doctor from their frontier area of South Dakota.

Upon examination, the primary care doctor discovers numerous medical conditions, including diabetes and hypertension, which had gone untreated. Uncertain of the diagnosis of John’s psychiatric illness, and the potential for interactions with the other medications he wishes to prescribe, the doctor arranges for a psychiatric consultation via telehealth.

Through video and other telecommunications equipment, John is interviewed by a psychiatrist 500 miles away at an Indian Health Service Facility. The psychiatrist is able to assess John’s appearance and body language. Having been advised by a cultural competence advisory committee, the psychiatrist knew how and what types of questions to ask John about his use of native healers and herbal remedies. She also is part of a program experienced in medication algorithms for mental disorders. She arrives at a diagnosis of bipolar disorder and recommends a medication regimen that would not interact with the diabetes and hypertension medications. Because of John’s older age, she recommends extremely low doses of the psychiatric medications. But she recognizes that the longer length of time for the antidepressants to take effect in older people (8 weeks rather than 4), combined with the lower dose, might leave John vulnerable to suicide. She suggests that the doctor work to establish communication with John’s native healer to monitor John carefully and to avoid giving him certain herbal therapies that might interfere with his medications.

Vignette 5— Illness Management and Recovery

Lupita, a 17-year old high school senior, arrived in a San Antonio emergency room after a suicide attempt. The psychiatrist on call happened to be the same one who had diagnosed Lupita’s bipolar disorder a year ago. He thought that she had been taking her medications properly, but blood tests now revealed no traces of lithium or antidepressant.

The psychiatrist tried to communicate with Lupita’s anxious parents waiting in the visitor area, only to learn that they spoke only Spanish and no English. She had mistakenly assumed that because Lupita, a second generation Mexican American, was highly acculturated, so were her parents. She contacted the hospital’s bilingual social worker who discovered that the parents felt powerless for months as they watched their daughter sink into a severe depression, all the while lacking the motivation to take her medications. The social worker, whose family had similarly emigrated from a rural region of Mexico, knew to gently ask the parents if they could read and understand the dosage directions for Lupita’s medication. Finding that the parents had limited literacy in both English and Spanish helped the psychiatrist and social worker to tailor a treatment program that would not depend on the written word. Seeing the parents as essential to Lupita’s recovery and knowing she lived at home, the psychiatrist encouraged the parents, through the interpreter, to accompany their daughter to an illness management and recovery program. The hospital had organized programs for Spanish-speaking families because Latinos are a majority group in San Antonio.

During the weekly sessions, the social worker translated for the family and helped them with scheduling Lupita’s psychiatric visits and to apportion the correct combination of pills in a daily pill container. Understanding that the family had no phone, the social worker worked with them to find a close neighbor who might allow them use of the phone to relay messages from her and to contact her if Lupita stopped taking her medications.

Vignette 6— Family Psychoeducation

When Kawelo lost his job as an electrician, his therapist asked Kawelo if he had a family elder who knew of community elders familiar with traditional Hawaiian healing practices for personal and family problems. The therapist knew that Native Hawaiians, in times of difficulties, rely on their elders, traditional healer, family, and/or teacher to provide them with wisdom and cultural practices to resolve problems. One such practice is ho`oponopono, which is a traditional cultural process for maintaining harmonious relationships among families through structured discussion of conflicts. Ho`oponopono is also used by individuals for personal healing and/or guidance in troubled times.

Kawelo’s therapist recognized the importance of tapping into this community support and suggested that his family seek out ho`oponopono. The therapist contacted the family and elders to arrange a meeting concerning Kawelo’s problems with depression, for which he needed both medication and counseling. At the group meeting the therapist further explained that Kawelo was so ill hat he lacked the motivation to receive treatment, and that his condition was so serious that he may be at risk for suicide. The therapist asked the elders how the group could help to encourage Kawelo to stick with his treatment and how they could watch Kawelo for suicidal signs. After lengthy deliberations, the family decided that one way to help Kawelo was to participate in ho’oponopono to understand the types of problems that he is experiencing and identify how the family could help him heal himself. Some members of the family also agreed to participate in a bi-weekly family psychoeducation group held at the community mental health center to learn more about his mental illness, coping skills and strategies, and pharmacological and psychosocial treatments. Through family psychoeducation the family would participate in structured sessions using a variety of educational formats. Because an important level of healing in Native Hawaiian culture involves sharing feelings and positive and negative emotions, in an open, safe, and controlled environment, the family’s participation in a combination of ho’oponopono and family psychoeducation was ideal.

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