Culture & Mental Health

By Rita Baron-Faust

It has been an extremely busy year, attending conferences, meetings, doing site visits and interviews (a listing starts at the end of the article). Everything has been so interesting! I am extremely grateful for this fellowship, which allowed me to turn down some freelance work so I could spend more time on my research project and do some traveling. I again thank the Carter Center for making it possible.

When I began the Fellowship, I planned to write a journal article or special communication directed at health care providers to alert them to the importance of cultural considerations in the diagnosis and treatment of mental disorders, and how different sites (including an HMO) are providing culturally competent mental health services; a radio series on culture and health for "Report on Medicine" for WCBS, Newsradio 88, and possibly a foreign language brochure on mental health issues or service (possibly for Bellevue Hospital Center).

By the end of the fellowship year I had amassed a great deal of research and taped interviews for the journal article. The writing of the journal article is now in progress, with more interviews and site visits slated for the fall. I am discussing the feasibility of a general brochure on mental health services to be translated (and back translated) into other languages with the heads of psychiatry at both NYU and Bellevue.

I had planned to travel to several cities to visit cultural psychiatry programs (such as the one directed by Dr. Francis Lu at San Francisco General Hospital). But I ended up feeling a little like Dorothy in the "Wizard of Oz." I thought I would have to go far afield to find interesting programs. Instead, I found them literally in my own backyard.

Almost immediately upon returning to Atlanta, I attended a three-day conference on culture and health at the New York Academy of Medicine, which provided me with invaluable contacts. In my own Brooklyn neighborhood of Sunset Park, I discovered a neighborhood outreach program for Chinese immigrants run by Luthern Medical Center, and a day hospital for Latinos with a chronic mental illness at Maimonides Medical Center.

As a result of my long association with the New York University School of Medicine (which provided peer-review for the last ten years for my daily radio program, "Report on Medicine" for WCBS Newsradio 88), 1 was able to gain access to a number of fascinating programs and people. Among them: an in-patient psychiatric unit for Asians at Bellevue, a bi-lingual treatment program for Latinos and their families, and the NYU Center for Global Health which is working on a number of fronts in the mental health field (including aiding refugees from Kosovo). This fall I plan to attend special training sessions for interpreters to aid in diagnostic assessment of mental health disorders among the diverse Bellevue population.

What was delightful (and frustrating) was that every time I made contact with one source, they immediately gave me the names of several others who were involved in programs around the city. The list is still growing.

The public affairs office at NYU was as intrigued by what I found as I was; I was asked to detail these culturally-specific programs in an article in a special issue of the medical school's alumni magazine, The NYU Physician, devoted to urban health issues. This will be published in November 1999. (The unedited draft manuscript is attached.)

During the year, I visited Brookline, Massachusetts, to interview officers of the Harvard-Pilgrim Health Care organization, a large managed health care group in New England. Harvard-Pilgrim has a four-year old program aimed at bringing cultural awareness to its providers. They have now started an annual course for practitioners, which I hope to attend.

I spent a very busy week in May at the annual meeting of the American Psychiatric Association. This year the APA featured more than a dozen symposia and clinical sessions on the issue of culture, which kept me running from one end of the convention center to the other and to surrounding hotels. Sessions ranged from the issues of violence and drug abuse in the Hispanic community to the difficulties of translating assessment questionnaires into other languages. I met a number of leading experts in the field whom I have been interviewing since then (and will also be talking to this fall).

I also visited Harvard Medical School to interview Dr. Arthur Kleinman, whose work has been seminal to the field of cultural psychiatry, as well as several of his colleagues.

Harvard is starting up a cultural-awareness course for physicians-in-training. The Weil College of Medicine at Cornell University in New York City has also initiated such a course. I was fortunate to be able to attend an eight-week course in cultural psychiatry for psychiatric residents at the NYU School of Medicine. Each one of these programs takes a different approach, which I'll detail in my presentation.

Unfortunately, my planned radio series had to be postponed when WCBS ended its decade-long relationship with NYU and myself, opting to use another producer/writer for "Report on Medicine." However, we are currently seeking to reformat the program and take it to a national audience. When that happens, the radio series will most certainly air.
So what have I learned?

When I began the project, my notions of culture and mental health were limited to issues discussed in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSMIV, 1995, American Psychiatric Press) and other books on culture and health I had read. While these were all fascinating, I have found that the real challenge lies in raising the awareness of practitioners, and in training providers to deal with specific populations. No cookbook approach is adequate to this task.

When I began this project, Jane Delgado gave me a piece of advice. "The language is important," she said. And this is very true. All the "cultural competency" training courses in the world will not make much difference if there are no providers available to speak the language of the patient and, importantly, to understand the requirements of mental health evaluations. Sometimes the psychiatric terms or concepts are hard to translate, or may be non-existent in a particular language or culture. After I attend the training course for translators at Bellevue, I will incorporate what I find into a special memo to the Carter Center and into my journal article.

I have come to believe that centers need to assemble multidisciplinary teams for different populations (depending on the area of the country) that include such translators, rather than relying on "on-call" interpreters, who may not always be available. Of course, this takes funding. Bellevue (and other city hospitals in other locations) have found a way to obtain those funds via grants from city and departments of mental health. This might be a worthy area for the Carter Center to consider creating small grant awards, since public funds are always at a premium.

Specialized clinics are expensive. No doubt about that. And in an age of budget cuts for urban hospitals and pressure from managed care, they may not always be feasible. But the facilities I visited required no special space or furnishings, only the vision and will to create them. Indeed, I was initially surprised to find that the Asian in-patient unit I visited at Bellevue did not have any uniquely Chinese furnishings. What it DID have were signs in English and Chinese, culturally-tailored recreation (Chinese chess and other popular games), and a Chinese menu, so that patients would not have to contend with strange and unpalatable foods. But what has made the unit special (and effective) was the staff, all of whom were fluent in different Chinese dialects, who were aware of cultural beliefs and family customs, and who were able to incorporate that knowledge into the very Western practice of psychiatry. Some were Asian themselves, but the unit is directed by a Latina psychiatrist. The stigma attached to mental illness in the Chinese community was also lessened somewhat by the environment, which provided comfort and support for patients and family.

The unit was created because the patient population already existed. The intent was to provide a culturally comfortable environment to help in the treatment of patients. Having a specialized population to study also benefited the institution, which will publish an article about the enhanced effectiveness of an atypical anti-psychotic in Asian patients, possibly due to genetic and racial factors. Community input is also important in creating such services.

Even a large HMO like Harvard Pilgrim can provide a framework for culturally-competent care by educating providers about the populations they serve.

Part of what I will write about in the journal article is how mental health has led the way in awareness of cultural issues in diagnosis and treatment. But it is now time to bring that awareness to a wider physician population. Studies by psychiatrists show that diagnosis of depression and anxiety by general practitioners is often impeded by lack of knowledge about cultural beliefs and culturally-influenced symptomatology and symptom reporting. Studies also show that providing culturally appropriate and effective care does not require racial or ethnic "matching" of provider and patient. I will cite several such studies in my presentation in September.

We also need to expand our notions of culture. "Culture" involved not only one's ethnic or racial background, but their language, their neighborhood, their religious affiliation, whether they have a job or not, their income level,whether they are married, single, gay or straight, and whether a person is a woman or a man. Gender is a powerful influence on many aspects of a person's life, a fact not generally appreciated by most health practitioners.

The cultural issues highlighted in the DSM-XV provide a rough roadmap, but cannot give an accurate picture of the terrain of people's lives. As the director of inpatient psychiatry at Bellevue told me: "At some point, one must put away the map and explore the terrain. It is only in doing that can we provide true culturally-appropriate care."

CONFERENCES & MEETINGS ATTENDED:

"Quality Health Care for Culturally Diverse Populations Provider & Community Collaboration in a Competitive Marketplace," October 2-4, 1998 NY Academy of Medicine.

On Site Interviews at conference with: Francis Lu, M.D., Director, Cultural Competence and Diversity Program, Department of Psychiatry, San Francisco General Hospital; Ira SenGupta, MA, Cultural Competency Training Coordinator, Cross-Cultural Health Program, Seattle, WA

Culture and Language Classes for Primary Care Providers (Chinese and Spanish), Bellevue Hospital, December 1998 - February 1999

Cultural Awareness Lectures for Psychiatric Residents, NYU/Bellevue Hospital Center. Instructor: Ernesto Ferran, M.D.
Assistant Professor of Psychiatry, NYU School of Medicine Director of Clinical Services, NYU Child Study Center
April 14, 1999 - Overview of Culture & Mental Health
April 21, 1999 - Cultural Considerations in Diagnosis
April 26, 1999 - Culture & Psychosis
May 4, 1999 - Culture & Psychopharmacology (Guest Lecturer: Jim Chou, M.D.)
May 11, 1999 - Mental Health Diagnosis in Asian-Americans (Guest Lecturer: Henry Chung, M.D.)
May 25, 1999 - Case Presentations
June 1, 1999 - Culture and the Treatment of Adolescents and Families (Guest lecturer: Tanya Royster, M.D.)

Cultural Committee Meetings at the Brooklyn Mental Health Council: "Cultural Sensitivity to Mental Health Issues in the Asian-American Community," January 21, 1999, Kenny Kwong, Ph.D., Other meetings: March 18, 1999 the African-American Community; April 15, The Orthodox Jewish Community, Joel Dinnerstein, M.S.W., Director, Cultural Committee. August 1999 (TBA): Follow-up interview with Dimitra Riseuno, Ph.D., Assistant Commissioner, NYC Department of Mental Health Brooklyn-Staten Island Borough Office, to assess results of program

CONFERENCES & MEETINGS ATTENDED:

American Psychiatric Association Annual Meeting
May 15-20, 1999, Washington, DC.
Sessions Attended Included:
May 17, 1999: Symposia: Psychiatric Diagnosis in Diverse
Populations; Cultural Aspects of Psychiatric Practice Across the Americas
May 18, 1999: Component Workshop: Substance Abuse, Violence and the Hispanic Family.
May 18, 1999: Scientific & Clinical Report Session: Culture and Race in Mental Illness.
May 19, 1999: Symposia: Cultural and Language Considerations in Diagnosis; Violence, Social Change and Women's Health.

September-October (TBA) Cross-Cultural Primary Care, 4-part Course for Residents, NY Presbyterian Hospital, NYC Instructor: Emilio Carrillo, M.D., M.P.H.

SITE VISITS & INTERVIEWS:

October 6, 1999: Interview with Francesca Gany, M.D., Director, New York State Task Force on Immigrant Health

November 19, 1998: Sunset Park Family Health Network of Lutheran Medical Center, Brooklyn, NY Interview: Virginia Tong, M.S.W., Special Assistant for Program Development (TBA: Follow-Up Interview)

January 20, 1999: Chinatown Health Clinic,
Interviews with Henry Chung, M.D., Medical Director,
Kenny Kwong, Ph.D., Educational Director

January 22, 1999: Interview & Tour with Manuel Trujillo, M.D.,
Director of Psychiatry, Bellevue Hospital Center; Bilingual
Treatment Program, Interview with Yvette Caro, Ph.D., Director

February 17, 1999: Harvard Medical School
Interviews with Arthur Kleinman, M.D.,
Alex Cohen, M.D., to discuss Culture & Mental Health

February 18, 1999: Harvard-Pilgrim Health Care, Brookline, MA
Interview with Barbara Stern, Vice President, Diversity

February 25, 1999: Gouverneur Diagnostic & Treatment Center Lower Manhattan, Asian Out- Patient Mental Health Programs Interview with Liz Kramer, co-author: "Immigrant Women's Health" (1998, Josey-Bass).

SITE VISITS & INTERVIEWS:

June 9, 1999: Global Health Center, NYU Medical School
Interview: Andres-Jacques Neusy, M.D., Director

July 1, 1999: Asian In-Patient Unit, Bellevue Hospital Center
Interviews with: Angelina DeCastro, M.D., Director;
Ricardo Casteneda, M.D., Director, In-Patient Psychiatry,
Bellevue

July 7, 1999: Interviews: Follow-Up Interview with Manuel Trujillo, M.D., Director of Psychiatry, Bellevue Hospital; Culture and Substance Abuse Treatment, Marc Galanter, M.D.; Structure of the Bilingual Treatment Program, Nereyda Brenner, Ph.D., Educational Director.

July 27, 1999: Bilingual Treatment Program, Bellevue Hospital Case Presentation Conference (attending a series of these Tuesday meetings on new patients)

FUTURE SITE VISITS:

September 1999 (TBA): Follow-up site visit to Latino Day Hospital at Maimonides Medical Center, Brooklyn, NY (Facility for Hispanic patients with chronic mental illness) and follow-up interview with Santos Rivera, D.S.W., Founder-Director

September-December 1999: (TBA) Medical Spanish Program for 2nd Year Students, NYU School of Medicine.
Instructor: Carlos Restrepo

September-October 1999 (TBA): Visit "Maria Paradox" Mental Health & Empowerment Group Therapy Session, Bilingual Treatment Program, Bellevue Hospital.

(TBA) Cultural Training Program, Harvard-Pilgrim Health Care, Bookline, MA.

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