Sunday, November 16, 2008

Culture in the New World of CSAs.

The stories are endless:
- A grandmother can no longer cope with her grandchild’s impulsive and uncontrollable behavior; she moved from Puerto Rico to Massachusetts, seeking help from her extended family. How can we find a Spanish-speaking psychiatrist to decide if he needs the medications prescribed him before moving here?
- A family of recent immigrants from Eastern Europe, needs help with their child’s severe toileting issues, but the concepts of “encopresis” and “behavioral therapy” don’t translate well into their native language. How can we find common ground on which to discuss this problem?
- A naturalized family of South Asian origin, loses a child to cancer. How can we help to parents, whose English fails them when they try to discuss their loss?

We practice pediatrics and provide mental health services in Worcester County,
where an increasingly diverse population arrives at our doors, expecting treatment that is “accessible, continuous, comprehensive, family centered, coordinated, compassionate, and culturally effective”. New initiatives, such as the Commonwealth’s Child Behavioral Health Initiative should help us do a better job. Screening will allow families and pediatricians to begin a conversation about the complex behavioral and mental health issues that affect and increasingly large number of our children. For families like those described above, however, the conversation can be somewhat one-sided.
The good news is that the language of the Community Service Agency (CSA) RFP really requires the agencies to ponder the extent to which they are are able to handle families with linguistic and cultural barriers to care.  The RFP, for example, calls on the agency to provide "Services are relevant to the culture, values, beliefs, and norms of the family and their community."  It also sets as one its strategic priorities to "Strengthen, Expand and Diversify Workforce", which has been identified by most in the field as one of the major challenges in doing this work.  20% of the points awards in the contract evaluation are for "Cultural and Linguistic Capacity and Responsiveness to Underserved Populations", which involves looking at both the client interface and the organization's commitment to cultural competence and institutional development of a diverse workforce.  Many of the leaders of the agencies in Worcester County have found this to be a useful to in identifying the strengths and weaknesses in their own organizations.  Certainly, the CBHI is to be commended for putting cultural and diversity in the center of the initiative.
That said, it is not clear where the workforce is supposed to come from.  We need therapists who speak various languages, and who understand how behaviors fit into the cultural mileau at home and in other venues.  We need to hear how families from diverse background understand what we in the "Western World" call mental illness.  
As with so many things we have a lot of work to do.

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