Cultural Competency

1. Cultural Competency Cross Cultural Issues and Trauma

2. Definition of a traumatic event A traumatic event is any event or events, which overwhelms our core capacity to cope. It results in an experience of personal threat to our safety and/or the integrity of our identity.

3. Complex Trauma Multiple and/or chronic exposure to developmentally adverse interpersonal victimization physical, sexual and emotional abuse and neglect domestic and community violence War

4. What Constitutes Cultural Diversity?Is Vermont Diverse? • Diversity • Racial • Ethnic • Religious • Immigrant/refugee status • Sexual orientation • Living in rural areas • Disabled youth • Socio-economic status

5. Vermont Diversity Demographics • 95.3% of Vermont population is Caucasian • 11% of Burlington population is non-white • 30% of public school children in Burlington are non-white • 28 languages are spoken

6. Socio-Economic Factors Income/poverty • 11.1% of Vermont population lives below poverty • 13% nationally • Caucasian: 13% • Black : 27.4% • Hispanic: 26% • Under 18 : 22% US Census, 2010

7. Cultural Competency • Organizations and personnel have values and principles and demonstrate behaviors, attitudes, policies that enable them to work effectively cross culturally. • Have the capacity to: • Value diversity • Conduct self-assessment • Manage the dynamics of difference • Acquire and institutionalize cultural knowledge • Adapt to diversity and the cultural contexts of the communities they serve

8. Linguistic Competency • Capacity of an organization and its personnel to communicate effectively to persons from diverse populations including: • Limited English proficiency • Low literacy skills • Individuals with disabilities Organizational , Cultural, and Linguistic Competence, NCTSN

9. Linguistically Competent Trauma Informed Services • Bilingual/bicultural staff • Cross culture communication approaches • Cultural Brokers • Interpreter services • Sign language services • Print materials in applicable languages • In alternate formats (i.e. Braille, audio) • Easy to read, picture and symbol formats

10. Rates of Exposure Relative to Diverse Backgrounds African American adolescents six times more likely to be murdered than white adolescents. Victimization is higher for people from lower socio-economic backgrounds and urban communities 90% of elementary school children in New Orleans witnessed severe violence Chicago survey found that 75% of 10-19 yr olds had witnessed a shooting or stabbing (Raia, J.A., Ph.D, Clinical Quarterly, Nat'l Ctr for PTSD, Fall, 1999)

11. Rates of Exposure Relative to Diverse Backgrounds Racial incidents can be traumatic and have been linked to PTSD among people of color Communities of color can have higher rates of PTSD than the general population LGBTQ individuals experience victimization and PTSD at higher rates than the general population (source: Leading Change: A plan for SAMHSA’s Roles and Actions)

12. Trauma and Homelessness An estimated 1 -1.6 million youth are homeless (National Alliance to End Homelessness, 2006) Racial and Ethnic Minorities are overrepresented among homeless youth 3-10% are LGBQI2-S Sexual abuse victims 17- 35% Physical abuse victims 40-60% (Robertson & Toro, 1999; Jenks, 1994). Up to 43 percent of homeless adolescent males and 39 percent of adolescent females report being assaulted with a weapon while living on the streets (Whitbeck & Simons, 1990)

13. Homeless Youth Runaway and homeless youth with previous histories of both physical and sexual abuse have the most severe psychological conditions Homeless youth with previous histories of abuse are greatest risk for revictimization (Ryan, Kilmer, et al., 2000). 75 percent of homeless youth use marijuana or other drugs (Kipke, O’Connor, Palmer, & MacKenzie, 1995; Green, Ennett, & Ringwalt, 1997)

14. Service Considerations Ensure that agency policies and procedures are not retraumatizing Universal trauma screening as part of the intake process Unconditional assistance. Provide access to lowbarrier services, such as a meal or a hot shower, while they are developing trust. Consider behavior in the context of their life experiences including their traumatic histories. Remain available while still setting limits. Prioritize youths’ immediate needs.

15. Determine the youths’ strengths and talents Allow homeless youth to make their own choices whenever possible, including about treatment. Assess cognitive abilities in order to use appropriate and understandable language. Assess psychosocial needs and refer them to complementary services to augment treatment. Offer referrals only to youth friendly agencies. Tailor interactions and treatment plans to individual needs. Use of trauma-exposure therapies is discouraged due to high incidence of have comorbid substance abuse disorders and lack adequate support and basic safety (Thompson, McManus, & Voss, 2006).

16. Attend to co-occurring disorders and other mental health problems that need to be addressed. Ask about current sleeping arrangements at each treatment session and pace interventions accordingly. Willingness to open up to a mental health provider is often directly correlated to how safe they feel when leaving the service provider’s office. Engaging and retaining these youth in treatment is challenging, even for the most skilled clinicians. Use a harm reduction model

17. Childhood Trauma World-Wide • In the past decade > 2 million children killed in war. • 6 million were wounded • One million orphaned • More than 300,000 youth serve as child soldiers. • Female soldiers often sold in to sexual slavery • (United Nations High Commissioner for Refugees)

18. Refugee Youth • Refugee • A person who is outside his/her country of nationality or habitual residence • Has a well founded fear of persecution because of his/her race, religion, nationality, membership in a particular social group or political opinion • Is unable or unwilling to avail himself/herself of the protection of that county or to return there for fear of persecution • Half of worlds 20 million refugees are children

19. Refugee Youth • Between 1998 – 2001 more than 1.3 mil. refugees admitted to the U.S. • Approximately 40% were under 18 • In 2003 more than 10,000 refugees under the age of 18 arrived in the U.S. • By 2004 number rose to 15,000 (US Department of State Bureau of Population, Refugees and Migration). • By 2008 numbers fell back to approximately 10,000 (BRYCS - Bridging Refugee Youth and Children's Services)

20. Refugee Youth • Between 1998 – 2001 more than 1.3 mil. refugees admitted to the U.S. • In 2003 more than 10,000 refugees under the age of 18 arrived in the U.S. • By 2004 number rose to 15,000 (US Department of State Bureau of Population, Refugees and Migration).

21. Phases of Refugee Experience • Preflight • Onset of political violence/war • Social upheaval, increased chaos • Limited access to school

22. Flight • Uncertainty • Children may be born during this phase • Displacement • Separation from caregivers • Resulting increase in vulnerability to victimization • Increase in mental health issues • Decreased positive outcomes • Basic needs uncertain • Unaccompanied minors: • INS (ICE) may detain unaccompanied minors in INS detention centers or juvenile detention ctrs.

23. Resettlement • New belief systems • Refugees escaping war and persecution are at higher risk of mental health problems • May encounter Western MH systems for the first time • Families may be disrupted • New family roles • Children as culture brokers • Faster language acquisition • Faster assimilation

24. Traumatic Bereavement • Refugee children may have lost family and friends in violent acts resulting in traumatic reactions. • Unable to go through grieving process • Re-Experiencing • Wish for revenge • Preoccupation with the experience

25. Traumatic Reaction Exposure to Trauma Hyperarousal Nervousness Hypervigilence Exaggerated startle reaction Insomnia Avoidance/Numbing Avoiding triggers of trauma Detached from others Unable to form relationships Re-Experiencing Triggers from daily events Dwelling on unbidden thoughts, memories, sights

26. Refugee Children and PTSD As many as 75% of refugee children meet criteria for PTSD (Allwood et al., 2002). Additionally refugee children experience acculturative stress (Berry, 1994: Birman et al., 2002). Few receive services Need for culturally competent approaches constitute a barrier to care.

27. Culture and Trauma: LGBTQ Youth 33% of LGB students reported attempting suicide in the previous year vs. 8% of heterosexual peers reported attempting suicide. 84% of LGBTQ students were called names or had their safety threatened due to their sexual orientation 45% of LGBTQ youth of color experienced verbal harassment and/or physical assault 39% of LGB students and 55 percent of transgender students were shoved or pushed.

28. LGBTQ Youth and Trauma 64% of LGBTQ students feel unsafe at school. 29% missed one or more days of school because they felt in danger. 25-40% of homeless youth may identify as LGBTQ. Parents or caregivers may force them out of their homes after discovering their child’s sexual orientation.

29. LGBTQ Youth & Trauma LGBTQ youth experience and are exposed to trauma in many ways: Physical and emotional assaults for “coming out,” or fear of being found out on a daily basis. Engaging in at-risk behaviors as a way to cope with confusion about their sexual identity. Barriers to finding a safe and trusted relationship as disclosure may put them at further risk of harm. The trauma of this "double bind" underscores the need for confidentiality and safety from a trusted helper.

30. Trauma and Deaf Children • Deaf children are at increased risk for traumatization. The ongoing communication barriers that often exist within the family and in other key settings can cause: • Increased frustration by adults and children; • Difficulty in teaching deaf children about safety; • A lack of educational resources such as safety curricula and sexual abuse/kidnapping prevention programs • Assumptions by perpetrators that deaf children are less able to disclose information about abuse

31. Difficulties in teaching/learning skill building and socialization • Decreased opportunities for incidental learning; • Decreased opportunities for trusting, open relationships; • Less disclosure of abuse to caregivers; and • Less understanding of the parameters of healthy/safe touching. • Deaf people may also experience • additional communication barriers • misunderstanding, and fear during the disclosure or • investigation of a traumatic event • Exacerbated feelings of isolation and difference after a traumatic event.

32. Service Considerations Find a certified interpreter that can commit to working with the deaf client. Get details about history of hearing loss and social emotional development. Assess history of language use and ability to communicate in multiple settings. Ask about educational background and school settings. Find out about the availability of culturally relevant supports.

33. Be aware of the oppression, stigmatization, and isolation that deaf people often face. • Consult with specialized providers about bringing a culturally affirming view of deafness into the work • Find out about the family’s past experiences with therapy and interpreters. • Working w/ an interpreter: • Prepare the interpreter for traumatic content • Debrief with the interpreter after each session.

34. Arrange physical placement to maximize your direct eye contact with client. Look and speak directly to the deaf individual, not the interpreter. Work with the interpreter to repeat or rephrase as necessary to ensure the client’s understanding. Remember that the interpreter has an ethical obligation to interpret all that is said in the room. Interpreter’s own history could affect his/her ability to interpret accurately; personal issues could lead to a violation of boundaries or a dual relationship between the client and interpreter.

35. Adapting individual child sessions Modify relaxation techniques to focus on visual and tactile aspects. A trauma narrative may need to be done with a more visual medium than writing. The therapist and interpreter together may need to teach the child and family appropriate signs and words for what has happened to them. The therapist may need to put more emphasis on increasing socialization skills and safety.

36. Effects of Exposure to Trauma Dissociation. Some traumatized children experience a feeling of detachment or depersonalization, as if they are “observing” something happening to them that is unreal. Behavioral control. Traumatized children can show poor impulse control, self-destructive behavior, and aggression towards others. Cognition.Traumatized children can have problems focusing on and completing tasks, or planning for and anticipating future events. Some exhibit learning difficulties and problems with language development. Self-concept. Traumatized children frequently suffer from disturbed body image, low self-esteem, shame, and guilt.

37. Trauma Informed System Trauma-informed services are not designed to treat symptoms or syndromes related to abuse or trauma. Instead, the primary purpose is to deliver mental health, addictions, housing supports, vocational or employment counseling services, etc., in a manner that acknowledges the role that violence and victimization play in the lives of most consumers of mental health and substance abuse services.

38. Trauma Informed System This understanding is used to design service systems that accommodate the vulnerabilities of trauma survivors and allow services to be delivered in a way that will facilitate consumer participation that is appropriate and helpful to the special needs of trauma survivors. Harris, M., & Fallot, R. EDS. (2001) Using trauma Theory to Design Service Systems, Jossey-Bass, San Francisco.

39. What Works • RICH: • Respect • Information • Connection • Hope • Empowering and Collaborative Relationships • Risking Connection, Karen Saakvitne • (

40. What Works Harris, M., & Fallot, R. EDS. (2001) Using trauma Theory to Design Service Systems, Jossey-Bass, San Francisco. • Power • Choice • Control

41. How Can a Teacher Help? • Provide a stable, predictable, comforting environment • Provide clear, consistent rules and expectations • Signal that you are available to listen • Never pressure a student to tell his/her story • Provide opportunities for students to tell their story • Remember that ‘bad behavior’ may be a traumatic reaction

42. Trauma Informed & Culturally Competent Provide Access to Tutors Display welcome signs in different languages Display photographs/items from different countries represented in the student body Have general class discussion about prejudice and stereotypes