 This episode was prerecorded as part of a live continuing education webinar. On-demand CEUs are still available for this presentation through all CEUs. Register at allceus.com slash counselor toolbox. I'd like to welcome everybody to today's presentation on improving cultural competence, working with Latino and Latina persons. And throughout the presentation, I will refer to this culture as Latino, Latina, Hispanic. So, you know, referring to the same kind of group of people. We're going to review the ecological framework, review the nuances in communication with Latinos, review cultural beliefs which may impact treatment or help-seeking, cultural values which are imperative for effective treatment. We'll explore Latino beliefs about health and illness, culture-bound symptoms, identify key psychosocial risk and protective factors, useful approaches for this population, how to modify psychoeducation to be culturally appropriate, and other strategies that may be helpful for counselors. So, one thing to be aware of, we're just kind of going to jump right into communication, is that when we're working with a Latino or Latina population or person, reading and writing are not common means of communication, especially among those from lower socioeconomic statuses. They're more oral traditions. So, yesterday we talked about Native Americans who are definitely more visually oriented in terms of learning. The Hispanic population is more oral and auditory in their learning. So, we want to pay more attention there. Verbal and nonverbal communications from Hispanics usually are characterized by respect. So, we want to give what we're getting, and we're going to talk more about that. There's an element of formality in Hispanic interactions, especially when older persons are involved. So, over familiarity is not appreciated, which, you know, in the majority culture, typically we don't appreciate over familiarity, but it's even more so. There's even more structure and hierarchy in the Hispanic culture. They tend to have less direct eye contact, especially with those who are perceived to have a higher status or to be older. And it's uncommon for Hispanics to be aggressive or assertive in healthcare interactions. They usually respond in silence and noncompliance. So, they may not ask questions, even if they don't understand. They may not say, that's not going to work for me, even if they know it's not going to work. So, it's incumbent upon us to really pull it out of them, so they feel empowered to say, that's not going to work for me. And helping them understand from the get-go that, you know, obviously we're from different cultures, but helping them understand that you recognize we're from different cultures and that whatever things that we may, that we, the clinician may propose, may not seem like they're going to fit as well for their values and everything like that. So, laying it out there and making sure they understand that if we say something that doesn't feel like it's going to work, they are totally welcome and encouraged to point out their points of view. Early attention must be given to developing rapport, which begins with an exchange of pleasantries before beginning the assessment or treatment for the day. So, it's not just taking somebody in the first time and having five or 10 minutes of, hi, how are you, discussion. Every time you bring the person back, and like I said yesterday, this does not include when you're walking down the hall, looking back over your shoulder going, how was your week? That's not it. You know, sit down, make eye contact, say, well, how are things going? Tell me what was new with you this week and kind of get that rapport and get that warmth going before you launch into the business. It takes two, three minutes, especially in successive sessions to do this, but it really sets a much different tone. Personalismo or politeness and courtesy is essential. It provides unconditional recognition of the essential value of each individual, and there's a slightly different definition a little bit later that says, basically, we take this essential value and skills and we say, let's take your personalized strengths and tailor treatment there. So, personalismo can also mean individualized or personalized treatment. Confianza or being trustworthy is based largely on personal relationships and rapport, not on how many certificates you have on the wall. So, the idea that a person knows us or is one of us far outweighs the person's credentials or professional accomplishments. Hispanics expect healthcare personnel to be warm and personal and express a strong need to be treated with dignity. So, we should be doing this with all of our clients. However, it's really important to make sure we go out of our way, especially if we're working with someone who is, you know, a recent immigrant to the country who may already feel like they're being oppressed. We want to make sure we make it warm and inviting and is empowering as possible so they feel like they're getting dignified treatment. Building Confianza, take time to get to know them as individuals and don't underestimate the importance of family to one's individual identity in Latino culture. So, yesterday we talked about, you know, don't ask questions that aren't related to the presenting issue, and that was for Native Americans for Hispanics. You really want to say, you know, how is your wife? How's your kids? How's things going? Ask about the family. Make sure they understand that you care. If Spanish is their primary language, make an effort to communicate with them in Spanish to some degree. It goes a long way. And again, remembering to use proper terms, and if you've had Spanish, you'll probably remember your basic como estas usted is much different and much more formal than como estas. Como estas you would use with a friend. So, you want to use the formal forms of the questions when you're talking to people. You're not going to do the whole session in Spanish, but if you make an effort to say, to greet them in Spanish, and if you make an effort to say goodbye in Spanish, that will go a long way, because you're showing that you're trying, you know, to develop some understanding. Try to avoid gesturing, because some may have adverse connotations. Now, I talk with my hands, and that's not quite gesturing, because you don't want to point or, you know, make hand signals. You want to try to restrict those as much as possible unless you know what those signals mean in that culture. Again, encourage patients to ask questions. Many Latinos place great importance on the practice of Roman Catholicism. Now, not all Latinos are Roman Catholics, so it's important to understand that. The central tenets of Latin Catholicism are sacrifice, charity, and forgiveness, which can in some ways hinder assertiveness, the whole sacrifice and forgiveness, but it can also be a source of strength and recovery. So helping them balance that dialect, where they can, you know, forgive without feeling like they're giving up or saying it was okay. And forgiveness is one of those concepts we talk about a lot in counseling. Now, in your class, I put a couple of resources, and here's one of them that I created for you. If you're not Roman Catholic, this is just a really quick and dirty primer. Saint Pope John Paul II said, whoever suffers from mental illness always bears God's image and likeness in himself as does every other human being. In addition, he always has the inalienable right not only to be considered as an image of God and therefore a person, but also to be treated as such. So Pope John Paul came out and said, you know what? Mental illness doesn't make you any less worthy, any less of a person. Let's not be ashamed by it. Let's not have this define a stigma or something. So that's good. The Catholic Church is embracing of people, even those who are struggling with mental illness. One of the things that a lot of Catholics do is pray Novenas. Novenas are kind of like prayers on steroids, if you will. They're prayers that you say in nine successive days in order to increase their strength. So there are different Novenas for different things. You can Google them. You can learn more about them. Then there's also morning and evening devotions. And we have something called the Sacred Heart Missile and Manual. You can find that on Amazon. You can probably ask your local Catholic priest or diocese to loan you one or to let you look at one. It walks you through the different masses and it shares the different morning and evening prayers that can be said. There are some of them that are very, I find as a Catholic myself to be very grounding. So that's another place where your clients may find some utility or some a way to use their faith in order to help them get grounded in the morning and get grounded in the evening to make sense of the day. Persianers priests are obviously going to help them find the right prayers and saints to work with if they're struggling with stuff. When they go to confession, you know, they'll take care of a lot of that. But it's also important to understand how important the saints are in Roman Catholicism. And there's tons of saints. You're not going to memorize them all, but you can look in the directory of saints and figure out which saints are for which issue and what the rosaries used for. Because praying the rosary is really important to many Catholics and the stations of the cross as well. On this sheet, I found several saints that are associated with mental illness and mental health recovery and even addiction and prayers that had been written to say to those saints. Just a sort of a little quick and easy primer for you to have. So if you're working with someone who is Roman Catholic, Hispanic or not, that might be useful. Along with Catholicism, the Latin culture often uses Magico religious ceremonies, which is candles with pictures of saints on them. So you'll see in a lot of Latin households these candles and they will be lit at certain times of year, certain times. People's relationships with the church is changing, though. And that's causing a little bit of disruption. The role of the Protestant and evangelical churches is increasing in the Hispanic culture. So that's another reason you can't just assume that they're going to be of Roman Catholic faith. And if they are from a different church, then figuring out what those belief systems are and how they find grounding and meaning. But it will be important to examine that, because as the church is sort of losing its footing a little bit with this particular population, they're trying to redefine themselves in terms of cultural change. Latinos can face somewhat different triggers for relapse relating to a culturative stress or the need to uphold particular cultural values such as personalismo. It's the use of positive personal qualities to accomplish a task. Remember we talked earlier about having it be personalized or individual. Machismo is the traditional sense of responsibility Latino men feel for the welfare and protection of their families. Now the machismo can be abused. Machismo in its cultural form and its pure form is a very nurturing, paternally centered sort of concept. La Familia is the collective identity, which is really a huge buffer for a lot of Latino families. The protective factors that come from La Familia include the warmth that they find from within their family, spontaneous expressions of concern, interest, understanding, and positive regard. And just a general sense of I've got belonging and somebody's got my back. And Jerraquismo is a respect for a hierarchy. Like I said, this culture is very hierarchical. Presentismo is an emphasis on the present. So we're not talking about the future. We're not talking about six months from now. We're talking about how can you improve things for yourself right now? What is going on with you right now? We're not focusing as much on the past, except for how the past is impacting you right now. Espiritismo is the belief that good spirits or evil spirits can affect the well-being and spirit of the dead person. So understanding that, you know, there is a belief in things that can happen to two people once even after they've died. Respect though is the consideration and deference to people who are older or of higher status. Agreeableness is another value. So if they're not empowered to say something, if we're not questioning, if we're not asking, if they feel like they're, you know, not supposed to say something, typically they won't. And sympathia is a chord or agreement and harmony in relationships, marriage, the family, and society. So this is a very collectivistic culture, much like the Native American culture, and they want harmony within the people, both at the individual and the micro and macro levels. The Latino paradox is something that I learned about doing this presentation, and that is that 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 may have lower average income and education. So they may have more stressors, but their mental health outcomes seem to be a lot better, or at least on par with. So, you know, what's that? And so we go back to looking, maybe it comes from that La Familia and the buffers that the family provides. Caregiving ideology of Latino cultures is exemplified by most Latino clients having families that live intergenerationally in the same household, very similar to other cultures that we're talking about. They also, like the Native Americans, have a fatalistic view, and they view illness as God's will or divine punishment brought about by the previous or current sinful behavior. So not a disruption in sleep, all of those biological organic things that we like to try to talk about or that I try to talk about a lot aren't going to really hit here. They tend to view a lot of this misery and distress as being a punishment that's brought down and caused. And there was another post that I wrote, and it's actually on the front of all CEUs right now, but the Book of Wisdom, for example, is a book that is only in the pre-Reformation Bibles, like the Gutenberg Bible, Eastern Christian Bibles and the Catholic Bible. So you're not going to find it in your King James Version. Wisdom, the Book of Wisdom, contrasts the destinies of the wicked and the righteous and emphasizes moral, not physical fruitfulness and points out that like in Job and even to some extent in Matthew, suffering does not presuppose sin. It points out that sometimes suffering is a trial by God in order to test you to see if you are worthy of Him. So examining how they view this current condition, what's causing it, what they think the meaning of it is going to give you a lot of insight into interventions and ways to help them. Latinos are less likely to use medical alternatives than are white Americans, so they're going to be pretty mainline. Some Hispanic patients may prefer, however, to use home remedies and may consult a folk healer known as a curandero. Physical or mental illness may be attributed to the imbalance between the person and the environment. So, you know, you've got punishments from God, but you've also got imbalances in that lack of harmony, if you will. Influences include emotional, spiritual, and social state, as well as physical factors such as humoral balance, which is expressed as too much hot or cold. I know that was hot and cold. Hot and cold are intrinsic properties of various substances and conditions. So, and there are sometimes differences in opinion about what's hot and what's cold, but in general, cold mental health diseases are things that are, and we're going to talk about this tomorrow when we get into Asian culture, referring to things that are more depression-oriented, slowing, lethargic, depressive, dark, damp, those kinds of words. Hot tend to refer to things that include anxiety and mania and conditions that tend to rev somebody up and get them going faster than, you know, what their baseline really is. Cold conditions are treated with hot medications and hot conditions are treated with cold medications. So, let's think about that. Do we practice that in Western medicine? Well, to a certain degree, we do. Cold medications are, cold conditions like depression are typically treated with medications in order to enhance the mood, to brighten the mood, to bring more energy to the person who is depressed. Hot conditions like anxiety tend to be treated with medications that are going to slow the person down, like benzodiazepines or bivituates, which, and other things, but if we're just talking about meds right now, you see that we're generally trying to help the person get back into balance. So, it makes sense, but understanding the terms hot and cold can help you understand your communications a little bit better. Latinos are more likely to believe that alcohol and illicit and prescription drugs will have negative consequences than our white Americans. So, they're more standoffish from the pharmacology and illicit drugs. Although, Puerto Rican participants were more likely than other students when we're looking at college students to see increased sociability as a positive expectancy related to drinking. Yet, they were also more significant, more significantly more likely to report abstinence from alcohol. So, they thought that it might help them be more sociable. They did have a positive expectancy, but they still said, no, you know what, I think I'm going to abstain anyway. In the Latino culture, it's believed that individuals who abuse substances cause their whole families to suffer. And in the majority culture, we can see how this is true, but since the Latino culture is very collectivistic, causing the family to suffer is like causing yourself to suffer. You're part of a whole. So, through this, you're hurting the body. You're hurting the family. Latinos typically believe that people who use illicit drugs will participate in violent crime and act violently towards family members. So, 78.9% of people believe who were surveyed believed that illicit drugs are going to cause major bad mojo. So, that's another reason they abstain from these drugs and try to stay away from them. Driving under the influence of alcohol is one of the most serious substance abuse problems in the Latino community. So, we do want to still look at DUI as in terms of assessment. We want to look at alcohol, misuse and overuse. Maybe it doesn't quite qualify for abuse yet. Drinking alcohol in the Latino community is part of social occasions and celebrations, which is probably why the DUI rate is high. But, it's also important to recognize that they don't see solitary drinking as okay. It's considered deviant. So, if you're doing it as part of a celebration, score. If you're doing it as part of a, you know, by yourself, if you will, it seemed as more problematic. Social norms for Latinas, however, the women are quite different. They're often perceived as promiscuous or delinquent in meeting their family needs and meeting their family duties and obligations if they're using substances, especially if they're misusing substances. So, there's a lot of looking, I can't think of the word, they're under a microscope more so than the Latinos, more than the men. A heavy emphasis on the idealization of motherhood contributes to the level of denial about the prevalence of substance use among Latinas. If you're seen as being a bad mother if you use substances, and being a mother is so important in this community, then if you are, if you do have a substance use issue, you're probably going to not want to admit it, which makes sense. So, when we're thinking about treatment options, we need to think about, all right, what are we going to do in order to help people out? So, moving on to culture-bound symptoms. Now, a lot of these are still in the DSM-5, which is good, they haven't been taken out, but Maldéojo is caused by a person with a strong eye, especially green or blue eyes, but admiration or jealousy at another person. Nervousimo is sickness of the nerves and is common and maybe treated medicinally or spiritually. So, we're going to look at that in Western medicine, we're probably going to call that more generalized anxiety. Susto fright results in soul loss. Susto may be acute or chronic and includes a variety of vague complaints, and women tend to be affected more than men. So, we talked about soul loss yesterday, some too. So, this is one of those culture-bound symptoms that's going to differ between Native Americans and Hispanic Americans, but it is something that they talk about and that's losing a part of yourself that gives you energy and vitality. So, we're thinking more persistent depressive disorder, major depressive disorder, if we're looking to try to push it into a DSM category. So, we said that some people who of Hispanic origin are going to tend to look at different home remedies and things maybe before going to the doctor. Part of that is because of access, because of financial resources, and part of that may just be a cultural belief that they can get the healing they need elsewhere and it's not a medical issue. So, they may start out with home remedies, and they'll go to relatives and neighbors, especially female relatives and neighbors who are supposed to be the nurturing and may look for home remedies there. The herbalists, gerbiteros, also may be consulted, as may massage therapists. Midwives may also treat children, so that's the next person that they might consider talking about. You notice counselors not anywhere in here right now. The quanderototal is the lay healer who performs healing ceremonies and healing services on both the physical and spiritual body. And the doctor naturalista can prescribe natural remedies without a spiritual component. So, depending on where they think the origin of their symptoms are coming from, they may go to any of these people first before coming to a traditional or a western medical doctor or, you know, a counselor. Barriers to treatment and these are the things that, to be culturally responsive, we really need to keep in mind. A lack of Spanish-speaking service providers. Some things, when you translate them from one language to another, just kind of lose stuff gets lost in translation. So, for a Spanish speaker to get their needs and wants and condition and everything understood fully, it may need to be done with a Spanish-speaking provider. So, that's helpful. Limited English proficiency is also another barrier, especially if there's not Spanish speakers available. Financial constraints make the many Latinos only seek medical care for serious illnesses. So, for depression, anxiety, they're not going to be coming in, which is probably going to end up manifesting in a serious physical illness later, but, you know, they can't go. They can't afford to go until it becomes a crisis. A lack of culturally responsive services. Fears about immigration status and losing custody of children while in treatment are two other things that really prevent Latinos from seeking help. And that's what Latinos especially because, remember, we said that if Latinos are idealized in that motherhood role, so if they're seen as having any deficiency, they may be afraid that they will lose custody. If they're not legal immigrants, they may fear getting deported, losing their children, et cetera. They may have negative attitudes toward providers because they've been treated less than with dignity, let's say. And, you know, it happens. I wish it didn't. But I've gone into emergency rooms. I've gone into health departments. I've gone into places where people will sit 45 deep and wait all day long for a 15-minute appointment. So I can understand where their negative attitudes may come from. Discrimination and lack of knowledge about available services can also be a major obstacle to seeking services. While I'm on this, if you go to the SAMHSA website, they have those free publications that I tell you guys about all the time. And the National Institute of Mental Health and the National Institute of Health as well, all three of those agencies have a lot of publications that you can order for free on different mental health conditions and even physical health conditions that are in English and Spanish. So you can get the Spanish brochures to have available. And they're written in a culturally sensitive and responsive manner which can help you educate your clients. The mental health quality of life among lesbian, gay and bisexual, midlife and older adults. So, you know, this is a very specific population we're talking about. But I thought it was important because, you know, this is one of the many subcultures within the Hispanic culture. This culture was significantly their mental health quality of life was significantly lowered compared to non-Hispanic whites. So we talk about people who are LGBTQ having a potentially more stressful or lower mental health quality of life in the general population. When we look at Hispanic population, it's even lower. So we want to look at, why is this? Well, some of the explanations have been higher levels of perceived stress related to the lower socioeconomic status. Higher frequency of lifetime discrimination in most Catholic churches, lesbian, gay, bisexual, transgender is not welcomed. I mean, let's just put it out there. So there's discrimination even from their church. So we need to look at what does this mean. And I'm not saying all Catholic churches, all priests do this. But in large part there is, they may experience some discrimination from their church as well as the discrimination that they may experience in society as a whole. And a lack of social connectedness among Hispanic LGBTQ adults. So they don't talk about it. There's not as many people who are openly lesbian, gay, bisexual, transgender in the Hispanic community. So they have difficulty forming and finding their identity with regard to their sexual orientation. Key psychosocial risk factors. Higher rates of depression and anxiety were found with longer exposure to the U.S. among Puerto Ricans, Cubans, Dominicans and other Hispanics and Latinos. But not other Central Americans. So depending on where the person comes from they may or may not experience more difficulty with acculturation and have higher rates of problems the longer they're in the U.S. as they struggle with acculturation, bicultural identity however they're acclimating. Perceived discrimination increased with the duration of time that they were in the U.S. So that's not surprising to me. But that is a psychosocial risk factor. So we can help advocate to reduce discrimination. And the size of close social networks shrank as time in the U.S. increased. The U.S. white culture tends to focus on success, competition, individualism and not collectivism. So a lot of the values that are so important in the Hispanic community are not paralleled here which may mean a shrinking of social networks as priorities shift in the acculturation process. But as they lose those social networks they lose that buffer that La Familia starts to disappear or dissipate so there isn't as much buffer against the stress. Retention of cultural heritage is positively associated with self-esteem and pro-social behavior and negatively associated with internalizing symptoms. Now if you remember positive association means as they the more they retain their cultural heritage the more they have a higher self-esteem and pro-social behavior. The more they retain their social heritage the lower their internalizing of symptoms. There's a different relationship. Biculturalism which involves retaining both one's cultural heritage and acquiring the receiving culture is even more facilitative of positive mental health and protective against internalizing symptoms. So if they're able to find a bicultural identity then they're going to be the best of both worlds if you will. Protective factors for this population. The role of spirituality and religiousness is emphasized a lot. Now that's not true of everyone. Again this is a generalization not a hard rule. Non-judgmental cultural attributions that convey personal warmth are also protective factors. So if we're warm if and the warmth that they experience within their own culture is protective. Cross-border resources can be seen as protective so if they've got family back from wherever they came from and they're able to communicate they're able to help one another out that's helpful. And familialism which enhances identity pride and loyalty. Familialism is the valuing of family considerations over individual or community needs and we've been talking about that. The nuclear family is the most basic and common social unit but many extended family members are also often present. Family involvement in health care is so common health care health care providers are strongly advised to encourage that involvement. You know generally when we're taking somebody back for their assessment we say alright mom or alright husband you know we'll be done in about two hours you can come back. When you're working with a Hispanic family you know some of those people may want to come back during the assessment and especially when you're getting to know the person and they're kind of sizing you up and developing that con vianza it can be helpful to invite with the patient's permission obviously the family into the assessment and into the process. Familialism the Hispanic Latino family structure tends to be patriarchal and follow a rigid hierarchical structure. So we talked about machismo well one example of machismo is the father or the oldest male holds the greatest power in most families and may make health decisions for the family so the dad may decide what happens in juniors treatment and you know everybody refers to dad men are expected to provide for and be in charge of their families marionismo means that the woman is the primary force holding the family and home together through work and cultural wisdom and is responsible for most parenting so very traditional gender roles. Women are expected to respect and submit to their husbands although privately some women may hold a greater degree of power recognizing this and you know not trying to upset the balance in the family is really important when working with that family and understanding that if you're doing an assessment for example with the wife what treatment recommendations you make may have to be okayed or agreed upon with her husband so if she's not able or willing to make a commitment right away you know that's okay maybe she needs to maybe she needs to talk it over with him perceived US social standing improved with years in the US and was associated with lower odds of mental health problems so if somebody stays in the US and their social standing starts to improve then their mental health tends to go up if they're just in the US especially the first two years it's really tough but you know they found that after about two years people start acculturating and if they start doing it well and achieve a higher social standing the risks of anxiety and depression and stuff will start to go down and an ethnic identity is another protective factor that was identified because it gives people a sense of belonging and pride and it can be an ethnic identity to you know their Hispanic cultural heritage it can also be bicultural you know they can be proud to be living in America now but also proud to be Mexican and that's cool but we want to help them figure out what is their ethnic identity approach components use personal Esmo expressions of concern interest in clients families and personal warmth that goes a long way value the most positive aspects of Latino cultural groups such as strength, perseverance flexibility and their ability to survive so when they come in let's talk about what are your strengths tell me how you've persevered how do you keep going this seems like it's really difficult for you right now what's keeping you going reward and highlight any flexibility that you see this culture is much different but they're adapting because it's important for their family so that flexibility really takes a lot of courage and a lot of strength and just their ability to survive in an oppressive world so we can look at all of those things and really bring those up as strengths that they can use to build on for their recovery Latino cultural groups view time as more flexible and less structured though so try to be upfront about agency policies regarding showing up for time however if you have the ability to be a little bit more loosey-goosey or flexible that's definitely preferred so if you have for example a walk-in clinic where you say okay you can walk in anywhere from 8 to 10 and or 8 to noon and you will be taken by the next available counselor that might be more helpful to a client or preferable to a client than telling them you've got to be here at 9 a.m. try to avoid framing non-compliance in Latino clients as resistance or anger it's often Palaeananga or the relaxed fight showing both a sense of being misunderstood and respect for you at the same time so you don't hear them, you're telling them to do things that just ain't going to work and they don't have any faith they're also deferring to your higher status so they're not going to tell you to go jump in a lake which comes out as non-compliance so we want to ask them what is it that's not working for you or what am I missing and try to open that conversation and try to understand better what they think would help them and instead of saying what am I doing wrong because they're probably not going to feel real comfortable with that we want to look at what else could we do that might work better what can we do right, what else might help you respecting women's choices when working with Hispanic clients can mean supporting empowerment to pursue new roles and make new choices embracing the majority culture or reinvigorating the positivity of the Latina culture to promote recovery while respecting and maintaining traditional family roles of women so helping them find their voice and find their identity whatever that is whether it's in the traditional culture or in the majority culture. Cognitive behavioral therapy for Latinos in mental health and substance abuse treatment is recommended because it's action oriented problem focused and didactic the didactic component can frame therapy as an educational and less shameful sort of experience because even though the Pope says you know everybody has issues and you're all you all have the image of God within you it's still potentially seen as a problem or a weakness so we want to make sure that people feel okay walking into the clinicians office and they're not pulling the hoodie up over their head going I don't want anybody to see me contingency management can work well too this is more in substance abuse when you've got some sort of rewards or positive things to give the person if they attend a certain number of sessions. Motivational interviewing very helpful and node link mapping which is we talked about it yesterday is like mind mapping it's a visual representation using information diagrams fill in the blank graphic tools and client centered diagrams or visual maps to see a concept so you can chart it out even if their language skills even if their English is not super strong if we're drawing it out they can see connections between moving to the United States and not being able to find a job and their stress level or something family based approaches that focus on conserving and cultivating Latino cultural resources rather than on reducing family conflict are also going to improve. If we conserve and cultivate their natural buffers and resources family conflict probably going to go down but we want to help them enhance and not focus on the pathology as much. La 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 way too much stuff for me to go into here I gave you the web link so you can go and look at that resource if you happen to be working with a large Hispanic population cultural assessment learn about each family members view about their cultural background history of the relatives illness coping strategies goals and expectations of treatment needs and desires of family members so you have Jane and she's coming in for the assessment she's the identified patient but you also have other family members in there and we need to find out was their view of what's going on what's their perception of the history of the relatives illness what coping strategies does he or she have how is it impacting the family what do you need how can you the family member how can we help you help your friend your family member and get this harmony back so we're not it's like going in and doing a consultation at an organization you're not just going to walk in and talk to one supervisor and go okay let's fix this you're probably going to do several different little focus groups and say okay what do you all need what do you see is causing the problems here that leading you to have low morale throughout the agency and how can we understand it and work with it and we're going to figure out what each person or each group or department needs and then we're going to create a more rounded formulation psycho education is really helpful it focuses on increasing illness knowledge and problem solving skills to understand a little bit more about depression what causes it and you know some of the things that we know cause it we don't want to negate the spiritual aspects we don't want to negate some of the other things that they think may be causing it but we do want to help them see all the other things that can contribute and that can help it consists of an educational content on the etiology biology symptoms and treatment of the problem and coping skills guidelines so we're going to throw out some things and say what do you think about trying this and walk through it go through it with worksheets have them talk it out a little bit to see if they feel like it's going to work for them each session allows for an initial engagement period structured didactic curricula and an interactive period to process the learned material the way I do my groups introduction five minutes get to know each other you know status report on everybody the next 15 minutes is teaching a skill and you know interactively teaching a skill but teaching it and then we take a little break for like five minutes to let the reflective learners kind of process everything we get back together and the rest of the group is spent talking about okay think about a time last week when you could have used the skill something that happened how might you have used it and how might it have changed the outcome of the situation and then you know we go around the circle and do that and then think about something that may come up next week or when do you think you might be using this tool in the next week and why do you think it might be useful to you and that helps people start talking about it and if we need to help people individualize it a little bit then great we can do it then because they're thinking through it and they're basically doing little role plays in their own head to figure out alright are there any speed bumps are there any barriers that I see to implementing this helpful questions and assessment for anybody in the assessment room not just the identified patient what do you think caused the 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 and how long do you expect it to last if they've had episodes before they may know that it lasts for a month or they may know that you know it doesn't ever seem to stop what problems has your sickness caused you so and this is really vague this is very general does it cause problems with your family with your work with your energy with your health you know whatever so tell me about the problems that are caused by this what do you fear what are you concerned about with this sickness what kind of treatment do you think you should receive you know do you know of anybody who's had a similar issue and something's worked for them and you want to try that let's start talking about what options you've already been flipping over in your mind a little bit and what are the most important results for you to receive from this treatment so what's your goal it may not be the same as my goal so what are the results that you're looking for and then from there you can develop that integrated formulation and treatment plan programmatic strategies that are helpful socialize the client to treatment clients are likely to benefit from orientation sessions that review treatment and counseling processes and introduce staff so they feel like you know they're not walking into some scary place it's I don't want to say home away from home but for some clients if they're especially intensive outpatient or in drop-in centers it can feel like a home away from home so we want them to feel comfortable we want to reassure them about confidentiality because many Latinos especially undocumented workers or recent immigrants are fearful of deportation we want to look at client counselor matching based on gender and that seems to be more important than client counselor matching based on culture when working with the Hispanic population so a female client would prefer to be with a female clinician most of the time client program matching is another strategy for enhancing retention they found that many clients respond to ethnic specific programs especially for Latinos so if they're in a program that is mainly populated by other Latinos the retention rate seems to go up so what can we do just kind of summarize we want to provide bilingual services when possible use family therapy as a primary method of treatment because the family is really involved in the recovery process and it's a central component of the person's life and it's a huge buffer if the family is functioning well assess cultural identity and acculturation level for each family member because if you have one family member that is totally embraced the majority culture and one family member who has not done it at all and you have three other family members that are somewhere in between then you can see where there might be some conflict about what the proper goals are what the proper interventions are what the proper values are for recovery so it's kind of important to understand because as especially as the younger generations become more acculturated the older generations or the people who were the first generation to move to the community and the older generations may have difficulty accepting the changes in the culture determine the family's level of belief in traditional and complimentary healing practices and integrate these as appropriate if they want to bring in a full killer if they want to bring in their priest or not necessarily bring them in or let's talk about what to do if they don't want to go to support group meetings but they'd rather go to church every day that's one great thing about Catholics we've got church every day if you want to go and that can be a support for the person discuss the family's beliefs history and experiences with standard American behavioral health services maybe they've tried treatment before and it just didn't work it felt like the counselor didn't even hear their concerns or was trying to lead them in a direction that wasn't the direction they wanted to go or maybe they went to a facility and they weren't treated with respect the counselor was always running late and seemed to be hurried and was never prepared we've seen it happen it's unfortunate but it does but if we talk about that then we know what some of their trigger buttons are because they've experienced that before in a bad situation we can make sure we prevent it explore migration and immigration experiences if appropriate and provide additional respect to the father or father figure in the family so showing additional deference to that person if that's not your identified patient making sure to greet that person when you go out into the waiting room if you're bringing their wife or their child back and make a little bit of small talk with him or her if appropriate in order to show that you recognize that that person is the head of the family interview family members or groups of family members separately to allow them to voice concerns kind of like going into an organization and having little focus groups you know sometimes you need to separate the children from mom and dad but that's going you're going to have to feel your way around that and see what's comfortable for that family as far as separation versus everybody being in the same room generate solutions with the family and don't force changes in family relationships provide specific and concrete suggestions for change that can quickly be implemented because the quicker like anybody the quicker they start seeing progress the more motivated and engaged they're going to be focus on engaging the family just the client the family in the first session using warmth and personalismo focus on their individual characteristics and what makes them unique and awesome as a family group leaders should allow members to learn from each other and resist functioning as a content expert or representative of the system otherwise members could see group therapy as oppressive so when you're running a group ask people what's your but what's been your experience what would you do in this situation instead of lecturing at them all the time because that falls flat and even if you're doing a psycho educational group presenting a tool then asking what it what about this do you think sounds like it might work and what do you think sounds like it now it's just not going to work for you ask them because you know they're the experts on themselves and helping them feel more empowered to tailor treatment and speak up is going to be important okay are there any questions if you enjoy this podcast please like and subscribe either in your podcast player or on youtube you can attend and participate in our live webinars with Dr. Snipes by subscribing at allceus.com slash counselor toolbox this episode has been brought to you in part by allceus.com providing 24 seven multimedia continuing education and pre-certification training to counselors therapists and nurses since 2006. 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