DESK REFERENCE Universidad Central del Caribe PO Box 60327 Bayam贸n , PR 00960-6032 787-785-5220 ph 787-785-4222 fax www.ATTCnetwork.org/hispaniclatino firstname.lastname@example.org email@example.com
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Published on September 2013
Cultural Elements in Treating Hispanic and Latino Populations
Page 2 GLOSSARY
Why a desk reference?..................................
Familismo (Familism): The whole is greater than the sum of its parts………………………. Respeto (Respect): Recognition of the uniqueness of others………………………….. Confianza (Trust): A valuable piece for engagement …………………………………… Personalismo (Personal relationships): Between provider and client …………………. Espiritualidad (Spirituality): Connection between faith and health ……………………...
Acculturation: The process of changing one’s cultural orientation set of beliefs, attitudes, customs, language, and behaviors. Culture: The thoughts, communications, actions, customs, beliefs, values, and institutions of racial, ethnic, religious, or social groups. Defines who people are, their history, their families and their world view. Cultures also provide explanations about why behaviors occur and supply appropriate responses.
Culturally and linguistically appropriate services: Health care services that are respectful of and responsive to cultural and linguistic needs.
Hispanic and Latino: Defined by the Census of the United States as a person of Cuban, Mexican, Puerto Rican, South or Central American or other Spanish culture or origin regardless of race.
Machismo: Is a gender-specific value that applies to Latinos. Refers to a man’s responsibility to provide for, protect, and defend his family. Marianismo: Is a gender-specific value that encourages Latinas to use the Virgin Mary as a role model of the ideal woman. This includes the expectation of self-sacrifice of a mother on behalf of her children.
Personalismo (Personalism): The valuing, building and preference for close personal relationship.
Respeto (Respect): Implies a mutual and reciprocal deference, and dictates appropriate deferential behavior towards others based on age, sex, social position, economic status, and authority. Often in the Hispanic population, older adults expect respect from those younger, men from women, adults from children, teachers from students, and employers from employees. Simpatía (Kindness): Refers to an emphasis on politeness and pleasantness even in the face of stress.
Page 18 WHY A DESK REFERENCE? Machismo Machismo denotes a strong sense of masculine pride. In Latino culture machismo is more than just a word as it is so embedded in the culture that it is not only accepted, but often even expected. Machismo is usually used and defined with a negative connotation (male as aggressive, rude, emotionally insensitive and hyper masculine); however within the traditional Latino culture, â€œmachoâ€? also has good aspects that are usually neglected. The cultural value of machismo can be a value of strength. Latino men are expected to be caring, responsible, decisive, strong of character, and the provider and protector of the extended family. The context in which this value is viewed can help or get in the way of effective treatment and recovery.
For a complete bibliography of the original product, please visit: www.attcnetwork.org/hispaniclatino.
Providing clients with competent services and helping people understand the benefits of adopting healthy lifestyles are essential components of the good practices behavioral health care professionals attempt to accomplish. Unfortunately, behavioral health care providers face some obstacles, including cultural misunderstandings and limited availability to attend long training events or review extensive scientific literature about the different populations they serve. This desk reference includes condensed information for behavioral health care providers that may need to assure delivery of cultural competent care to Hispanic and Latino clients. The purpose of this desk reference is to provide concise and easily accessible information about important cultural elements in treating Hispanic and Latino population. This desk reference is based on Cultural Elements in Treating Hispanic and Latino Populations Curriculum. If you need additional information on this topic, please visit our webpage: www.attcnetwork.org/ hispaniclatino.
Page 4 INTRODUCTION Successful treatment for clients’ with substance use disorders (SUD) requires an expert mix of science, clinical training, pragmatic experience, and continuing development of clinician skills. This desk reference is written as a quick aid for behavioral health care providers for improving their skills in response to treatment challenges presented by clients from Hispanic and Latino1 populations. This desk reference is subdivided into the following main topics:
Familismo (Familism) Respeto (Respect) Confianza (Trust) Personalismo (Social relationships) Espiritualidad (Spirituality) Special considerations
It is now common to think about addiction as a “chronic relapsing disorder,” meaning that individuals with substance use disorders have a propensity to fall back into previous substance use patterns and lifestyles. Breaking the trajectory of addiction requires a concerted effort that mobilizes the individual to change and to sustain that change over time by making concrete changes in self-image and restructuring their lives. Findings from research indicates that addiction is a brain disease because long-term regular use of substances eventually causes changes in the brain’s chemistry and functioning affecting behavior.
GENDER ISSUES Hispanic women with SUD can be expected to be particularly difficult cases to treat primarily because Latino families stigmatize them in a more complete and isolating manner than they do male family members. In a pop culture society that glamorizes alcohol consumption and substance use, the mixed messages between family expectations, peer pressures, and mainstream media can be confusing. Also, within the Hispanic culture women are supposed to be highly controlled and circumspect regarding their personal demeanor and guardians of their maternal role. Motherhood Motherhood, historically, has been fundamental for the formation of Latina self-concept because is nearly a sacred status. Marianismo, the expectation of selfsacrifice of a mother on behalf of her children, is prescribed by cultural convention and reinforced through families, social networks, religion, and public imagery in mass media. Mothers are expected to be nurturing, accepting, and willing to deny their personal desires on behalf of their children. The well-being of her children is expected to be the dominant source of a mother’s happiness. Because of these, Latinas with SUD who have children pose a particularly difficult situation because they will experience guilt about neglecting their children or because they have been separated from them and their parents will scorn them for failing to be good mothers.
These two processes are often intertwined but it is useful to distinguish them in order to understand how they have shaped the life course of clients leading them to the present moment. Immigration and resettlement involves many contingencies. The process of immigration and resettlement can be relatively uncomplicated and complete, or in the other extreme, can last years and separate family members for extended periods causing irreparable emotional harm. Each immigrant family has a unique story to tell about their rite of passage for becoming Americans, even if they don’t recognize themselves as such and remain committed in spirit to their culture of origin. For the behavioral health care provider it is certainly worth hearing the story of a family’s immigration process.
Did the resettlement process disjoint families? Were children separated from parents for long periods of time, and did it affect their relationship? What was the impact on the structure and cohesiveness of the family, how was the family reconstituted, and was continuity maintained with the extended family in the nation of origin? What occurred in the resettlement process? Were many moves required, and were family and close friends available to supply assistance or not?
Of special interest is the extent to which parental relations were improved, damaged, or changed by the transition.
There are equally formidable psychological and social factors that influence the personal decision to be treated, including recognizing and fully appreciating the problem, deciding to act, finding a provider, and maintaining the commitment to recovery over time, even in the face of upsetting personal circumstances. The result is that many people with substance use disorders can mull over their decision to seek treatment for long periods of time before acting, and depending on the type of treatment they are seeking and local availability of care, it may be years before treatment is initiated. Most persons with substance use disorders will repeatedly enter treatment, and may often relapse. The science of addiction treatment is focused on how to minimize this history of recurrence. The interjection of cultural knowledge and skills about Latinos is intended to support treatment approaches that have shown to be useful through scientific evaluation of results, and to improve their effectiveness. FAMILISMO (FAMILISM): THE WHOLE IS GREATER THAN THE SUM OF ITS PARTS Hispanics and Latinos are known for having strong family ties. Latinos reference to familia (family) may often expand beyond nuclear and extended family to include not only parents and siblings, but grandparents, aunts, uncles, cousins, close friends, and godparents. This bond often creates an obligation felt by fellow members to help and support each other when experiencing challenging life issues such as financial struggles, health concerns, and/or unemployment.
Many Latinos will put the family’s needs before the individual’s, and many Hispanics frequently consult with other family members and often ask them to come along to medical or treatment appointments. While the children of immigrants face conflicts provoked by the unequal “Americanization” processes among family members, the United States (U.S.)-born families are already highly “Americanized” in most instances, and are inherently at higher risk for intergenerational substance abuse problems, and problematic family histories if they are low income. An effective way to think about how culture affects treatment is taking into consideration the client’s relevant history including family ties and conflicts, precursors to SUD, lifestyle, personality traits, treatment history, and how substance use is currently affecting their daily lives, and support systems. Many of these personal profiles may vary greatly depending on whether they are men or women, immigrants or U.S.born, and if their families and peers speak English or Spanish. The most critical aspect is whether they have maintained ties to family members or have “burned their bridges.”
Does their family of origin remain important to them, do they live with them or see them frequently, or is the relationship more symbolic than real? For most Hispanics family usually remains important even when things have gone very badly in the past due to the substance use lifestyle. Are their friends, spouses, or romantic partners welcome in the homes of their families ,or are they seen as outcasts?
Some Hispanic clients, particularly those who are older or are recent arrivals in the U.S., may have traditional syndromes, symptoms, behaviors, or illnesses that are unfamiliar to U.S.-trained health care providers. They may also use folk medicine or traditional healing practices and beliefs that may include herbal medicine, spiritual and manual therapies or exercises in order to prevent, diagnose, treat or cure an ailment or illness. Depending on the client’s country of origin, he or she may have different terms for such traditional illnesses, syndromes and healing practices. It is suggested that the service provider acknowledges the patient beliefs, and asks about these syndromes and practices and how they are experienced by the client and his or her family. Respecting and understanding this view can prove beneficial in treating, communicating and building trust with the client. SPECIAL CONSIDERATIONS IMMIGRATION: A UNIQUE STORY OF RESETTLEMENT Out of the approximately 52 million Hispanics living in the U.S. in 2011, 19 million were foreign born2 and an estimated 11.1 million were undocumented residents. More than half of the nation’s 16 million Hispanic children were born to at least one foreign-born parent. Immigration represents two major sources of stress: 1. 2.
Family dislocation, fragmentation, and reconstruction. Cultural change for individuals and across generations.
ESPIRITUALIDAD (SPIRITUALITY): CONNECTION BETWEEN FAITH AND HEALTH Providers often work within the structures of mainstream medicine, which delivers separate physical and mental health care. Hispanic culture, on the other hand, tends to view health from a holistic point of view. This view implies a continuum of body, mind, and spirit. Spirituality is a very strong motivational trigger for Latinos. A client’s strong spirituality or religion may also provide foundation to build on recovery, but there are dangers. Religion can cut both ways, and stressing religion rather than spirituality can be counterproductive when family have condemned a family member with substance use disorders precisely because of their religious beliefs. For clients and families where religion influences how one's behavior is seen as sinful, or outside of the religious beliefs of the family, there is a stressor associated with resolving, absolving, releasing or healing from the dysfunctional or destructive consequences of behaviors stemming from substance use. Surprisingly, even in families with troubled histories and relations their symbolic importance can remain very high, and a valuable tool in shaping motivation for Hispanic clients. It is important to take in consideration that Latino patients may combine respect for the benefits of mainstream medicine, tradition, and traditional healing, with a strong religious component.
Newer therapies such a motivational interviewing are more flexible because they supply a method for incorporating Latino cultural orientation and highly valued cultural beliefs, and symbols into the motivational process. For example, stressing the importance of the family, protecting and providing for dependents, and the clear role and legitimate expectations of fathers and mothers. RESPETO (RESPECT): RECOGNITION OF THE UNIQUENESS OF OTHERS A high percentage of Hispanics are not retained in treatment or recovery services (either individual or group interventions) if they are not directed by a culturally sensitive leader, perhaps because they are not culturally accustomed to sharing their personal problems and issues with others who are perceived as “strangers.” This is especially true if they are part of a group program where the group leader or members uses aggressive “attack” methods intended to break down defenses, which violates Latino norms of respeto (respect) and simpatía (kindness) which anticipate reciprocity, and a confidential supportive relationship to exist before intimate information is shared or advice and criticisms can be advanced. An additional barrier to treatment retention is that the group may be filled with ethnically diverse people, and only English would be spoken. A culturally aware group leader can create, and sustain an appropriate environment of hope, and cooperation that will allow Latinos to feel the necessary comfort level for active participation.
Latinos who have SUD often confront with fear of having their “hidden problems” revealed to families, and the shame that accompanies this revelation for women with children, and the implication that male seeking help are not in control of themselves, and are not sufficiently resilient to manage their personal problems. Also, the traditional counseling method of reproaching people with SUD, questioning their ability to “stay clean” on their own, and focusing on their demonstrated powerlessness to resist temptation may be inappropriate with many Hispanics because this approach lacks warmth and acceptance. Group programs composed of individuals that have little shared experience with Latinos and their culture may be a bad fit. Similarly, therapists who are culturally tuned out or antagonistic may have a similar impact. It is recommended that out of sense for respeto the health care provider try to improve communication with the client and his or her family. The health care provider should:
Utilize trained interpreters when providing services with Hispanic clients who are not proficient in English. When using an interpreter, arrange the seating so that the provider faces the client, and have the interpreter sit alongside or near the client. Avoid using friends, family members, or children for interpretation. Use appropriate titles, such as Señor for Mr., Señora for Mrs. and Señorita for Miss, even if the service provider does not speak Spanish. If the service provider speaks Spanish, may show respect by using the more formal usted rather than tú (you).
PERSONALISMO (PERSONAL RELATIONSHIPS): BETWEEN PROVIDER AND CLIENT Latinos tend to stress the importance of personal relationships, and expect health providers to be warm, friendly, and personal, and to take an active interest in the client’s life. Personalismo (personal relationships) encourages the development of warm and friendly relationships, as opposed to impersonal or overly formal relationships. Establishing a good rapport with Hispanic clients may take a few extra minutes, but even small efforts can go a long way. It is recommended that the behavioral health care provider:
Offer the client a personal greeting to help him or her feel comfortable prior to any intervention. The Latino client often develops loyalty to the health care provider and other regular caregivers, which can have significant implications for continuity of care. Listen carefully when a client is speaking, and take care not to appear distracted or uninterested. If the service provider seems hurried, detached and aloof, the Latino client may experience resentment and be dissatisfied with care. This may reduce the likelihood of compliance with recommendations for treatment, follow-up and recovery. Should be attentive; take his or her time, show respect, and exhibit confidence.
CONFIANZA (TRUST): A VALUABLE PIECE FOR ENGAGEMENT
Do you know your clients?
Latino culture is diverse. Understanding the importance of culture for a person creates a meaningful opportunity for clients to culturally inform the treatment process and helps to disclose family or personal history. This interpersonal communication helps to create the intercultural dialogue essential to trustbuilding, and setting the stage for effective and acceptable delivery of services. An effective exchange and reciprocal discussion set the stage for disclosure of a personâ€™s cultural values and validates the personal, deep, and meaningful experiences that a client brings to the table. This exchange, and sometimes storytelling, or certainly plĂĄtica (informal chat) naturally shares the beliefs, values, and a personâ€™s worldview. When the Hispanic clients feels there is confianza, they value the time they spend talking with their health care providers and are more likely to believe what they advise. Providing treatment services that are culturally informed and culturally effective demonstrate a willingness to learn, incorporate, infuse, adapt or use practices and approaches that augment and compliment the modality, or program in use by treatment providers. A Latino who understands that he/ she is to be valued as a client; as a paying customer; as a cultural being with his/her own set of unique and diverse characteristics; and as a partner in recovery will reciprocate with his/her trust, openness, and involvement far better than someone who is fearful, reluctant to disclose, or further stigmatized.
To know Hispanic clients, is to know who they are, who their family is, what is unique about their culture and place of origin, and their motivation for getting well. After all, a client is his/her own personal content expert. This means that developing skills, knowledge, contact, influence and trust with Latino clients creates the environment for their reciprocal engagement in treatment.
Behavioral Health is Essential To Health • Prevention Works • Treatment is Effective • People Recover
RECOVERY... ...is possible if culturally and linguistically competent care is provided for Hispanic and Latino populations suffering from substance use disorders.