Train the Trainer: Implementing The National Cultural and Linguistically Appropriate Services (CLAS) Standards The Why,

1. Train the Trainer:Implementing The National Cultural and Linguistically Appropriate Services (CLAS) Standards The Why, What and How Cathy Cave Unlimited Mindfulness Consulting cathycave@verizon.net 518-461-6242

2. Why? We don’t see things as they are, We see things as we are. Anais Nin

3. We are our families. Sandi Cook

4. Cultural Considerations:Primary and Secondary Dimensions Employment Community Networks Geographic Location Family/Extended Family Immigration Status Class Income Economics Political Context Country of Origin Race Ethnicity Sexual Orientation Self-identification Language Culture + History Knowledge/Experience Marital Status Military Experience English Language Proficiency Gender Age Parental Status Perceptions of Physical Qualities Physical Abilities Education Literacy Primary dimensions influence “who” an individual is. Spiritual Beliefs Secondary dimensions influence an individual’s participation. (adapted from Rasmussen, 1996)

5. Who am I? How do I Identify?What are My Community Connections? ______________________________ ______________________________ ______________________________ ______________________________

6. Virginia Demographics US Census Bureau

7. Examples of Ethnic Diversity • For people of African descent • 6% foreign born (Caribbean & African immigrants) • Generational African Americans • Caribbean population: e.g., Dominican Republic, Haiti, Jamaica • Among American Indians & Native Alaskans there are > 560 separate tribes & > 200 indigenous languages • 42% of American Indians reside in rural areas

8. Examples of Ethnic Diversity • There are at least 43 separate ethnic Asian groups • Three (3) major subgroups in U.S. population are designated by the generic term Asian: • Asian Americans (Japanese, Chinese, Filipinos, Asian Indians, and Koreans • Asian Pacific Islanders (Hawaiians, Samoans, and Guamanians) • Southeast Asian refugees (Vietnamese, Cambodians, and Laotians)

9. Make It Local • What is the makeup of the community as a whole? • What is the makeup of the people who utilize services? • Race, ethnicity, age, gender, language, economics, sexual orientation, spirituality

10. It is much more important to know what sort of a patient has a disease, than what sort of disease a patient has. William Osler

11. Surgeon General’s Supplemental Report; Culture, Race, and Ethnicity in Mental Health Documented disparities for people of color include: • Less availability and access to services • Lower likelihood of receiving services • Greater likelihood of receiving poorer quality of care and disproportionate treatment outcomes • Over represented in hospitalizations (more restrictive settings) • Under represented in research 2001

12. The President’s New Freedom Commission Report on Mental Health “The system has neglected to incorporate respect or understanding of the histories, traditions, beliefs, languages and value systems of culturally diverse groups.” 2003

13. Media Response to the IOM Unequal Treatment Report New York Times, March 22, “Subtle Racism in Medicine” “ . . . a disturbing new study by the Institute of Medicine has concluded that even when members of minority groups have the same incomes, insurance coverage and medical conditions as whites, they receive notably poorer care. Biases, prejudices and negative racial stereotypes, the panel concludes, may be misleading doctors and other health professionals.” 2002

15. Social Foundation for Disparities: • Stereotyping: Influences how one can interpret a person’s current, past, and future behavior • Racism and Oppression • Oppression and Intersecting Oppressions: • Anti-Semitism • Ageism • Sexism • Heterosexism and Homophobia • Able-ism (disability)

16. EARLY YEARS Misinformation Missing History Biased History Stereotyping Socialization CYCLE REINFORCED BY Stereotypes, Omissions, Distortions, People, Systems, and Institutions From Those We Know, Love, and Trust Family Neighborhoods Education - School Media Government Houses of Worship The Confrontation & Engendered Feelings ANGER GUILT CONFUSION ALIENATION Cycle of Oppression Cycle Continues WE COLLUDE • Oppressed and Oppressor • We Have Internalized the Process • We View the Misinformation as Truth • Difference = Wrong or Abnormal • The systemic processes keep the majority in power Take a Stand Internalization Dismantling Racism, 2000

17. Privilege • Usually an unearned benefit • Some have more than others • Often invisible to those who have it • As providers, we all have some privilege • It is possible to have privilege and be part of a marginalized group • Low socioeconomic status matters (SES)

18. *people with disabilities *who are LGBTQ *people who are homeless* Marginalization: “The Club” Culture, Community, Social or Political Group with Power and Privilege *people who are elderly* are women* *adolescents* immigrants* *people with limited education *limited English Proficiency* *people who are poor *are overweight *who have mental illness* *people of color*

19. What is Culture? “The shared values, traditions, arts, history, folklore, and institutions of a group of people that are unified by race, ethnicity, nationality, language, religious beliefs, spirituality, socioeconomic status, social class, sexual orientation, politics, gender, age, disability, or any other cohesive group variable.” (Singh, 1998).

20. What’s Culture Got To Do With It? Culture determines views about difference, whether illness exists, if one should seek help, where to go for help, what is helpful, and what the path to recovery looks like.

21. Culture Impacts Service Acceptance and Effectiveness • Beliefs about traditional healing • Use of alternative, and complimentary practices • Treatment and Outcomes • Differences in drug response, dosing, side-effects, misdiagnosis • Consequences of illiteracy, low health literacy and language barriers

22. Factors That Influence Medication Effectiveness • Culture and ethnicity • Lifestyle and everyday practices • Natural healing practices • Environmental/lifestyle factors • Diet, tobacco/substance use or abuse, exposures • Genetic factors • Drug metabolizing enzymes • Biological factors • Age, gender, disease state, physiology, other medical problems

23. Health Literacy • Almost half of all American adults, 90 million people, have difficulty understanding and using health information to make good healthcare decisions • Health literacy goes beyond language and the individual. It is the providers responsibility to ensure that service users and the people in their support systems understand all aspects of their care

24. What?Cultural Competence is a Means of Eliminating DisparitiesDHHS 2001; Smedley. Stith, & Nelson, 2002; DHHS, 2003) Cultural Competence: “ . . a set of congruent behaviors, attitudes, and policies that come together in a system, agency, or amongst professionals, which enables that system, agency, or those professionals to work effectively in cross-cultural situations.” (1989 Bazron, Cross, Dennis, Isaacs)

25. Use What You Know… Knowledge, Information and Data Fromand About Individuals and Groups Integrate & Transform Clinical Standards & Skills Evidence Based Practices Service Approaches & Techniques Program Marketing that match the individual’s culture and increases both the quality and appropriateness of health care and health outcomes. (1997 Davis)

26. How? Culturally and Linguistically Appropriate Services [CLAS] Standards • The 14 standards are organized by themes: • Culturally Competent Care (Standards 1-3) • Language Access Services (Standards 4-7) • Organizational Supports for Cultural Competence (Standards 8-14).

27. Types of standards; mandates, guidelines, and recommendations: • CLAS mandates are current Federal requirements for all recipients of Federal funds (Standards 4, 5, 6, and 7). • CLAS guidelines are activities recommended by OMH for adoption as mandates by Federal, State, and national accrediting agencies (Standards 1, 2, 3, 8, 9, 10, 11, 12, and 13). • CLAS recommendations are suggested by OMH for voluntary adoption by health care organizations (Standard 14).

28. Measuring and Planning for Cultural Competency • Know you are doing the right thing! • Set standards and do evaluation • Find out from consumers and families what works! • Plan for change

29. Organizational Cultural Competence Assessment • Examine community demographics • Assess successful service areas • Examine service gaps, (Where is the need?) • Assess agency language assistance services capacity • Utilize strategies to increase acceptability of the message • Engage the community in service design and delivery

30. A Practical Look at Cultural Competence • Examine all service components for practices that inhibit or prohibit engagement • Seek meaningful inclusion of cultural considerations throughout the planning process • Intake • Informed Consent • Identification of Supports • Health Literacy • Diagnosis • Treatment and Medication • Active Service User Participation in Treatment Decisions (Shared Decision–Making)

31. The “Way In…” • Utilize outreach strategies and engage Cultural Brokers • Modify intake practices • Support meaningful family and community involvement • Obtain feedback from service users and their families • Use feedback to make change

32. Seek to Understand • What are the cultural influences impacting upon this person and their family? • By understanding, acknowledging and tending to an individual’s multiple memberships and identifying connections, helpers can avoid making inaccurate generalizations on the basis of appearance, language, abilities, or family name.

33. Maintaining an Asking Stance at Intake and Beyond Cultural Assessment • How would you describe yourself? • Tell me about your family? • What language do you speak at home, at work, or with friends? • Is spirituality or religion important in your life? • Do you have a religious or spiritual practice now? • Who or where do you go to for comfort?

34. Cultural Assessment is Ongoing . . Remember the culture is not the problem. It is the task of caregivers to assist consumers and families to navigate their individual path to healing. This requires personal awareness, cultural knowledge, and flexibility. Continue to actively engage service users and their families in the process of learning what cultural content is important. Keep in mind that there are no substitutes for good skills, empathy, caring, and a good sense of humor. “Nancy Brown”

35. Consider… • Many cultural connections • Your own identity may be a barrier • Your responsibility to gather information about the community • Assume nothing • Turn “facts”into questions • Search for and identify strengths

36. You can go anywhere if you’re cool enough!