cultural competency cross cultural issues and trauma
TRANSCRIPT
Cultural Competency
Cross Cultural Issues and Trauma
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.
Complex Trauma Multiple and/or chronic
exposure to developmentally adverse interpersonal victimization
physical, sexual and emotional abuse and neglect
domestic and community violence
War
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
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-white28 languages are spoken
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
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
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
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
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)
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)
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)
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)
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.
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).
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
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)
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 therefor fear of persecution
Half of worlds 20 million refugees are children
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)
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).
Phases of Refugee Experience
■ Preflight
Onset of political violence/war
Social upheaval, increased chaos
Limited access to school
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.
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 disruptedNew family roles ■Children as culture brokers
Faster language acquisition Faster assimilation
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
Traumatic Reaction
Exposure to Trauma
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
Hyperarousal
Nervousness
Hypervigilence
Exaggerated startle reaction
Insomnia
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.
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.
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.
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.
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
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 eventExacerbated feelings of isolation and difference after a traumatic event.
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.
■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.
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.
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.
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.
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.
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.
■ RICH:
Respect
Information
Connection
Hope
■Empowering and Collaborative Relationships
Risking Connection, Karen Saakvitne
• (
What Works
What Works
■ Power
■ Choice
■ Control
Harris, M., & Fallot, R. EDS. (2001) Using trauma Theory to Design Service Systems, Jossey-Bass, San Francisco.
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 storyRemember that ‘bad behavior’ may
be a traumatic reaction
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