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Moderator: Hello and welcome everyone!
This is Marcela Aguilar from the Substance Abuse and
Mental Health Services Administration's Disaster
Technical Assistance Center or SAMHSA DTAC.
I will be your host for this webinar.
Now, Let's begin with the Applying Cultural Awareness to
Disaster Behavioral Health webinar.
The webinar will feature Ms. Lori McGee,
Training and Curriculum Manager of SAMHSA DTAC,
Dr. Monica Indart of Rutgers University,
Dr. Kermit Crawford of Boston University and
Ms. Almarie Ford of the Louisiana Office of
Behavioral Health.
I would now like to introduce Ms. Lori McGee.
Ms. McGee serves as the Training and Curriculum
Manager for SAMHSA DTAC.
She has more than 11 years' experience working with
program and curriculum developers to improve services
using evaluation findings.
At SAMHSA DTAC she supervises the development of
training both in person and web based.
She is also the lead on the crisis counseling
assistance and training program activities.
Ms. McGee has worked with at risk and delinquent
youth populations, populations receiving
mental health services, women and families in
crisis and minority students.
She has prior experience in providing counseling and
legal services to survivors of domestic violence and in
developing programs to reduce and prevent violence in schools.
Ms. McGee holds a bachelor's in psychology from Barnard College
and a master's in criminology and criminal justice from the
University of Maryland, College Park.
Please welcome Ms. Lori McGee.
Ms. McGee: Hi everyone, thank you Marcela.
I just want to thank everyone for joining us today, and
especially our presenters.
I am really looking forward to everything they have to say.
I just want to say a few words about SAMHSA DTAC.
We were established to support states, territories, and tribes
to deliver effective behavioral health in response to disasters.
When we say behavioral health, we do include both
mental health and substance abuse.
We offer many services, primarily
consultation and trainings.
This can include a cadre member or one of our consultants
going out into the field or providing training.
We provide dedicated training and technical assistance for
disaster behavioral health response for grants such as
FEMA's crisis counseling assistance and training program.
We also do some work around identification and promotion of
promising practices in disaster behavioral health.
We have had a recent series of webinars with the
disaster behavioral health planning.
That would be one of the kinds of work that we do that
falls into that category.
In addition to those services that we provide,
we also have many resources.
I encourage you to call us or contact us if you have any
disaster behavioral health needs, regarding resources.
If you go to our website you will see disaster behavioral
health preparedness and response and specific
Disaster Behavioral Health information series.
We call those our DBHIS, they have toolkits and resources
geared towards specific populations or specific
disasters such as a flood or a tornado.
One of the pieces of materials that we have is
the developing cultural competence in disaster
mental health programs.
If you are looking for more literature related to
today's webinar topic you can contact us and
we can get you some copies of that as well.
If you prefer e-communications,
we have several e-communications that go out.
We have the SAMHSA DTAC Bulletin which is a monthly
newsletter that contains various resources that come out or
field events that are upcoming.
You can subscribe by emailing the address
you see here on your screen.
We also publish The Dialogue, this is
a quarterly journal; it is articles that are written by
professionals in the field and you can subscribe by going to
SAMHSA's website and following the instructions
you see here on the slide.
Finally, we have the SAMHSA DTAC discussion board.
This is a more casual place where we go to post
resources and have conversations about
different topics related to disaster behavioral health.
We sometimes ask questions of you and get your feedback or
response and you can subscribe by going to
the web address that you see here.
That is my quick overview of what we do.
If you find yourself in any need of technical
assistance or training regarding
disaster behavioral health please call us.
We have a toll-free number 1-800-308-3515.
You can also email us at dtac@samhsa.hhs.gov
or you can go to our website and browse around and
see what else is offered.
Dr. Amy Mack is our Project Director; she extends
her welcome and her contact information is here as well.
So, we'll get to the good stuff now.
Moderator: Thank you so much Ms. McGee.
The goal of today's webinar is to provide information,
recommendations and tools that can be used to
assess and strengthen cultural awareness practices in
disaster behavioral health services.
We will begin with Dr. Monica Indart who will focus on
guiding principles of cultural awareness and
their role in disaster behavioral health.
We will then hear from Dr. Kermit Crawford who will
present the challenges of addressing cultural issues when
providing disaster behavioral services.
We will end with Ms. Almarie Ford who will discuss
her experiences and lessons learned from applying cultural
awareness concepts and techniques in supporting
the disaster behavioral health needs of survivors.
Following each presentation our guest speakers
will respond to questions.
The learning objectives of today's webinar are to provide
guiding principles and recommendations for applying
cultural awareness to disaster behavioral health, to provide
cultural awareness best practices specific to disaster
behavioral health preparedness and response and to provide
tools that can be used to assess and strengthen cultural
awareness practices for disaster behavioral health services.
I would now like to introduce Dr. Monica Indart.
Dr. Indart is a clinical and community psychologist with
nearly 30 years of experience working in
crisis intervention, trauma, and disaster response.
She is a Visiting Assistant Professor at the
Rutgers University Graduate School of Applied and
Professional Psychology.
Dr. Indart has worked with various cultural communities
following disasters in New Jersey.
She provided training, consultation, and technical
assistance to the United Nations in ongoing development of their
crisis and disaster response and preparedness programs and
provided psychosocial assistance to survivors of
torture in Uganda and Rwanda.
Please welcome Dr. Indart.
Dr. Indart: Thank you for the introduction and
good afternoon everyone.
I want to thank SAMHSA DTAC and my co-presenters in
participating in this webinar which I think is
critically important, obviously, to disaster behavioral health
but for all of the continuum of services that we provide.
My goal is to provide an introduction to the topic and
then segue into my esteemed colleague,
Dr. Crawford, who will be talking more about
challenges and complexities in this.
I am going to be providing a framework and
a macro perspective for us to discuss some of these issues.
The first issue that comes up is terminology.
Cultural competence has been the term that we used for
a long time and we are re-thinking this in some ways,
not to throw the baby out with the bathwater but rather than
cultural competence, we are thinking of it in terms of
culture and competence.
As our society becomes more diverse, as we become
more sophisticated in understanding what is helpful
in terms of interventions it can be beneficial to reframe
our understanding to include a broader understanding that
looks at difference and diversity and a continuum of
competencies and skills and abilities in providing
culturally good care, or culturally responsive care.
Some of these terms can mean cultural responsiveness,
cultural sensitivity and certainly the term
cultural competence that we have all become familiar with.
It may be that we come to see cultural competence as
an ideal that we strive towards.
We are introducing a term of cultural awareness as
an emerging preferred term that reflects two aspects.
One is this universally helpful idea of compassionate curiosity.
Regardless of who you are working with and in what
part of the world you are working with,
people respond to this feeling that they get
from us as responders of compassionate curiosity.
The other part of cultural awareness is that it implies
the dual aspects of culturally responsive care, which is
being aware of ourselves and our own cultures,
our own biases, our own limitations as well as
the cultural values, beliefs and needs of
the people in communities that we are working with.
The next two slides are graphic representations of what it means
to integrate aspects of cultural awareness into
disaster behavioral health.
It is a bit of a simplification but we have
two possible scenarios that emerge, both of them
reflect an emergent and transitory disaster culture
so that every disaster has its own unique fingerprint, is
how I like to think about it, and its own culture.
One scenario is that we have two distinct or
fairly distinct cultures.
One is the culture of survivors and
the other is a culture of responders.
We have responders who are not necessarily a part of
the culture of the community or the geographic region come in to
provide assistance and in interacting, influencing and
being influenced by the culture of survivors they form an
emergent disaster culture that is transient and transitory.
An example of this may be some of what we experienced
here in the New York metropolitan region after 9/11,
when we had people not just from all over the country
but in some ways all over the world come to assist us.
Many of those folks were familiar with the cultural
diversity of this part of the country but many were not.
We had in some ways a distinct culture of responders and
a distinct culture of survivors.
The second possible scenario-- again, keep in mind these are
general points-- is where we have the culture of survivors
and the culture of responders, really a mixed culture that
is endemic to the geographic region,
to the area where the disaster occurs.
The responders come from the culture of survivors and
together this complicated mix again creates an emergent,
transient, temporary disaster culture.
An example of this may be hurricane Katrina and what was
experienced in the Gulf states, for example in New Orleans where
many of the people who were affected who come from,
as this slide describes,
the culture of survivors, also became responders.
They had the dual experience of being a survivor in that
particular culture and that disaster as well as joining
the culture of responders in providing assistance.
Keep in mind these are encounters in disasters and
that again, the situation that is created is a temporary,
transient, emerging disaster culture and that is
one of the foundation principles that we want
to have people keep in mind.
I am going to be describing culture as both
a bridge and a foundation.
Again, Dr. Crawford is going to elaborate on these ideas
much more eloquently but keep in mind as
a starting point that culture provides a bridge;
it provides a way of understanding human experience.
Here human experience can be simplified to include these
two pillars of influence.
One is biological, what we are born into the world with,
our race, our culture or ethnicity, our temperament and
those kinds of aspects.
Then, what is learned, what we acquire through
the socioeconomics background that we come into the world with
or that we achieve, sociopolitical influences.
Culture provides a bridge between these two pillars of
experience and it helps us define how
we understand the world.
It is a lens of how we understand the world
that is that fundamental.
It also provides a foundation for us.
Here I like to tie culture to crisis responsiveness because
culture provides the responsiveness in
the term crisis response.
Culture is how we embody a feeling of responsiveness for
the people that we work with.
It is at the core of crisis and disaster response.
It implies awareness of difference and diversity, as
I mentioned earlier, what is experienced
as well as what is expressed.
I will talk a bit about that next.
Awareness of individual needs and the competencies
we require to meet these needs of the people in
the communities we serve.
It allows us to better understand what is expressed
and listen for what is experienced so that
we can provide what is needed.
An example of how some of this gets played out-- if
I can just say from recent experience-- I just returned
from Rwanda where I have been doing some work for the past
several years and there 17 years after the genocide in 1994
we have now a second generation of communities coming into
being and trying to cope with the long term effects of
genocide and the horrors that occurred from that.
What is expressed is oftentimes quite different
than what is experienced.
It takes a long time to win the trust of people who are
different from us and who experience us as different so
that we can understand that what people experience is not
always what they express and we have to understand both
in order to be able to meet what they need.
To have that kind of subtle understanding and
appreciation is another part of culture as a foundation.
Perhaps in some ways the best way of understanding the
critical importance of cultural awareness is to take
a look at the negative aspect, which is cultural non-awareness
and how that can lead to what we think of as non-competent care.
Here we see that it is more than just a principle of care,
it really defines good care.
What happens when we are not culturally aware,
culturally responsive and competent to meet the needs of
the communities that we serve, is that it results in a sense of
disconnection for both ourselves and survivors.
Survivors start to feel disconnected from sources of
hope and healing, they start to feel a sense of
disillusionment that life and circumstances can improve,
that there is caring and compassion in the world.
They start to feel and experience an increasing of
distress, so that as hope fades despair and
distress emerge again.
Lastly, this can lead to dysfunction and as we know from
studying long term traumatic experiences that
dysfunction can extend across generations.
Lastly, these negative experiences are not just
survivors but also what we as responders can feel when
we start to feel disconnected from the people that we serve
and that, in extreme cases, can lead to things like burnout.
There are some substantial costs to non-competent care.
I just want to segue quickly into evidence-based practice and
talk about what in the world that has to do with culturally
competent or culturally aware care, and it has a lot.
Here is a very quick definition you see on your screen from
the American Psychological Association that looks at a very
common sense and pragmatic definition of evidence-based
practice that focuses on client characteristic,
culture and preferences and focuses on outcomes.
What I really want to emphasize is that at the heart and soul of
evidence based practice is looking at two things:
who are the people we serve-- and that very much includes
the person's cultural background-- and secondly
the focus on outcomes.
What is most helpful to a particular client or
community or group?
Under what circumstances?
We are looking at how culture influences positive
outcomes of adaptation, recovery and healing.
I am going to, if it's ok, leave questions for the end,
if that's alright with folks.
The next slide that you see is a graphic representation of this.
Again, clinical expertise, that includes the clinician,
our own cultural awareness, the research evidence,
the focus on outcomes, what is helpful for who and cultures at
the center of that as well as client values and preferences.
Obviously, we have culture at the center of
that experience as well.
How much cultural awareness is tied to
evidence-based practice is what we want to emphasize here.
On your screen you see a photo I took a number of years ago.
I was in Uganda, these are the Agape Peace Dancers,
they are former child soldiers and they go from
village to village dancing and singing their messages of
peace, hope, unity and reconciliation.
We included the slide to remind us that healing comes in
many forms and that these forms are rooted in rich
cultural traditions and here is a photo example of one of
those traditions and of healing and recovery in
action and a particular culture.
In 2003 SAMHSA published a handbook Developing
Cultural Competence in Disaster Mental Health Programs,
Guiding Principles and Recommendations.
It was developed by Dr. Jean Athey and
Dr. Jean Moody-Williams with the assistance of
many experts in the field.
The last part of this introduction is going to
review the nine principles that were included in that guide.
It is still extremely useful and very pragmatic and
I encourage all of us to use that.
I am going to take each of these nine principles and
move them a little bit forward so that eight years
down the road from when this guide was developed,
emphasizing how we can operationalize these principles
in today's evolving, complex matrix of culture and
disaster response and what we can do that is going to
promote cultural awareness.
The first three really introduce the idea of
culture and diversity and highlight the importance of
recruiting disaster workers who are representative of
the community or service area, which we all know.
If we move these principles a bit forward, again this is
our adaptation of an operationalization of
these concepts, we find that culture is not just a buzz word,
cultural awareness is not just the popular term or concept of
the day, it is really how we define good care and
what that means is that we have to get out and know people.
We have to get out of our offices, managers and clinicians
alike, and get in to the street so to speak.
How I operationalize this is we have to meet the people
we treat in the street.
We have to develop meaningful relationships with people
that are engaged and sustained for long periods of time,
clinicians and managers must do this in order to be able to have
the kind of collaborative relationships that define
culturally aware care.
The next three principles from the 2003 guide emphasize
the critical role of training and again,
we used to talk about this as cultural competence training and
that term may be redefined and expanded a bit, as we discussed.
Ensuring that the services are accessible,
that they are equitable and recognizing the role of help
seeking behaviors, natural support networks.
Clearly what we have understood over the last decade of
disasters is how important it is to use natural support
networks but first we have to understand them before
we can really use them and leverage them.
To emphasize, moving forward how we want to
focus attention on building and sustaining awareness and
that this includes a multicultural exchange.
A big part that I think we have not given sufficient
attention to is the role of fairness and justice as
critical principles that effect recovery,
particularly in communities,
large communities of refugees and immigrants.
Many refugees and immigrants have had varied experiences of
unfairness and injustice and those experiences have
colored not just their perception of the world and
the particular disaster or trauma they may experience but
what they can expect from us as providers and responders.
We need to integrate principles of social justice into
all of our interventions.
We need to be open to hearing about their experiences of
unfairness of injustice and we need to provide
interventions and relationships that are built upon these
principles of social justice.
Fairness and justice is recognizing the reciprocal
nature of aid and learning, we learn from one another and
we help one another.
For many immigrant and refugee populations what is
critical is for them to feel that this is a mutual process.
They don't want to take, but also give in the process,
that's the reciprocal nature.
The last three principles, the importance of cultural
brokers, identifying community leaders and
working with those leaders, linguistic and culturally
appropriate services and using cultural brokers and
leaders in evaluating the program's effectiveness.
Moving that forward, a bit of a tweaking of those
three principles, how important it is to have
real relationships.
It is not just enough to have these principles on paper.
Having a cultural awareness program is
a necessary but not sufficient condition for
agencies that is the term we like to use in science.
Cultural leaders have to be brought into every aspect,
every nook and cranny of the programs that serve
the communities that we provide interventions for.
From planning and delivering services to
evaluating and revising them.
It sounds a little corny but one of the things that
I like to think of is the allegory of the children's book,
The Velveteen Rabbit and here to recognize that these defining
principles involve essentially making compassion real.
The best way to make it real and keep it real is to have
a true collaboration and genuine partnership with these
cultures and cultural brokers in our communities.
Not just occasional meetings, not just
these quarterly trainings, but regular events,
all kinds of activities and opportunities where you come and
you eat together, you sit together, you talk together,
you laugh together, you argue together,
you celebrate your successes together.
Then, just as in The Velveteen Rabbit, when you
cry together that is when you have a sense that you have made
something real and sustainable and that will live on
past all of us in the community.
Just in closing I want to leave this quote by Azar Nafisi,
the esteemed Iranian author who wrote Reading Lolita In Tehran,
"In a place of knowledge we are all citizens of the world," and
I think that is a good segue to what I know will be
a very informative and viable presentation by Dr. Crawford.
I want to thank everyone and see if
I should be taking questions now.
Moderator: Thank you so much for your presentation, Dr. Indart.
I will now read the questions that we received for you.
We have three questions.
First one is, What are some of the major missteps that crisis
responders or behavior assessment teams tend to make in
regard to a lack of cultural awareness or sensitivity?
Dr. Indart: Whoever asked that question,
I want to thank you for being open minded.
By asking the question in a lot of ways you are
well on your road to avoiding a misstep because you recognize
that there are missteps to be made.
It reminds us that essentially the answer to that question is
we have to all be learning all the time.
If I had to quickly identify the top three missteps
it would be thinking that we know or believing that
we know how to respond to particular culture because
we have had cultural awareness or
cultural competence training.
This is an evolving process, we are never going to know
how to do things, we are going to understand the process of
how to do things but believing that we know
something I think can sometimes be a misstep.
It is not appreciating the humility that is involved.
The second one is being blind to our own biases.
That is a misstep.
We have to constantly be aware of our own biases,
that we have them, and to be honest about them and
how they may influence our behavior and actions.
I have to say this from my own experience,
another misstep is being afraid to take risks or
being afraid to ask questions.
We can't know everything and the only way we are
going to learn is to ask and that involves taking a risk,
it involves making ourselves vulnerable.
Being hesitant to do that has a price and that is a misstep.
That would be a short answer to that.
Moderator: Thank you Dr. Indart.
Our next questions is, Could you please give an example of
what is expressed versus what is experienced in order to
better understand this subtle, yet critical, difference?
Dr. Indart: I guess because it is fresh in my experience,
having just come back from Rwanda the day before yesterday,
in certain cultures there is a great deal of
emotionality experienced.
There is a great deal of suffering that is contained.
What is shown to the outside world, not just outsiders, but
even to people within the culture
can be a very small part of that.
The kind of suffering, the kind of internalization of
racism and social injustice that one has
experienced is not what is expressed.
If I can say, it can be easy to miss that, it can be easy to
miss the depth of suffering and the depth of injustice
that someone is experiencing.
It takes time and patience and that compassionate curiosity
to be able to understand what is going on in the inside,
not just what is shown on the outside.
It is only then that you can have some idea of
what the person needs.
If we just go by what they are showing on the outside,
in some cultures that is only a small piece of it and
that is all we will ever see.
I hope that helps.
Moderator: Thank you Dr. Indart.
Our last question is, What role do our individual biases
play in assessing what is expressed or what is needed?
Dr. Indart: Part of it may come from
our own cultural background.
I happen to come from a more Mediterranean/Latin culture and
we express a lot.
Not that we are expressing everything but a lot of times
we are expressing most things and I might miss that in
a culture where it is much more contained.
To be aware that our own background on either end of
the continuums and everything in the middle may influence what
we see because we are products of our own culture as well and
we have had our own culture to understand those two pillars of
human experiences that I described earlier.
To be aware of what may be our limitations and to constantly
keep that in the forefront of our mind and be asking ourselves
"What might I be missing here?"
And "How can I compassionately assess that and find that out?"
Moderator: Thank you again for your presentation Dr. Indart.
I now would like to introduce Dr. Kermit Crawford.
Dr. Crawford is a licensed psychologist and designated
forensic psychologist who serves as an Associate Professor of
Psychiatry and the Director of The Center for Multicultural
Mental Health at the Boston University School of Medicine.
He has provided response to and training for interventions
across a number of disasters since 9/11.
Dr. Crawford is the recipient of the Association of Psychology
Post-Doctoral and Internship Center 2011 award for
Excellence in Diversity Training.
Please welcome Dr. Crawford.
Dr. Crawford: Thank you, and I want to thank,
as Dr. Indart did, DTAC.
And I also want to say what an honor it is to be able to
present with my colleague Dr. Monica Indart and
my colleague Ms. Almarie Ford, whom I worked with for
months after hurricanes Katrina, Wilma, and Rita.
She was awesome.
I am going to talk about something a little different.
I know in these types of presentations people look for
breakthroughs, they look for magic bullets,
at least I know I do.
In this particular environment I think
that there are a lot of challenges.
In fact, I think that there are a lot more questions than
there are answers when it comes down to issues
related to culture, cross culture,
cultural awareness and cultural competence.
I want to focus a little on cultural competence first.
For the record, I think that cultural competence is worthy.
I think it is essential.
And at the same time I think that it is a myth.
I know this sounds contradictory, and it is,
but for me so too is the nature of cultural competence.
As I think about this particular slide when in deep stuff,
look straight ahead and keep your mouth shut and say nothing.
I think maybe too many times too many of us have,
around concepts in general that are right, that are correct but
someone at some point has to tell the emperor
that he has no clothes.
I think that-- again, in my opinion, as a pursuit of
a principle and as an aspiration,
cultural competence is top notch.
As a concept, a social construct
I think cultural competence has merit.
But as a theory and as a measure of practice
I think cultural competence is limited and is challenged and
has restricted utility.
I believe that by acknowledging its
limitations and contradictions that
we can more effectively seek the overdue, unmet promise of
this concept and that unmet promise is considerable.
I think this can also take away undue pressure on
responders and appropriately increase the urgency across
cultural awareness, knowledge and skills development
when not in response.
I see cultural competence as popularly viewed as having
at least four flaws, either of which could be
a fatal flaw for practice.
The first I would say would be the totality problem.
These are questions I have not yet been able to
sufficiently answer.
There is a definition of competence, there is
a definition of culture and those separate I don't think are
problematic but when you put them both together,
I think that to say that someone to be adequately or
well qualified in the totality of socially transmitted
behavior patterns, all other products of human work and
thought, I feel that it is a bridge too far.
I feel that it is almost an impossible task even before
the caprice of working on disaster sites and
in disaster response, the totality problem.
Next, I would say there is a numbers problem.
When I think of culture I think of the big eight,
raised, ethnicity, culture, gender--
you can see them there on the screen.
If we begin to combine these and think about
the types of people that we see, again thinking of
the totality of providing disaster behavioral health
services to these individuals.
Combining them we are talking about over 40,000 ways that
the big eight alone can be combined.
These are what people present with and this does not take
into account the quantitative differences in
self-identity or in multiple identities held by some people.
Cultural competence's very definition requires us to be
well qualified to work across all these types of differences.
The third problem, the idealization problem.
According to each prevailing model of cultural competence--
I am talking about Cross and Purnell and Campinha-Bacote and
others that I have read.
Practices should always approach cultural competence as
a standard but never achieve cultural competence.
If you look at the slide, the red line would be
the standard of cultural competence and the blue line on
the Y axis would be behavioral health response practices.
These practices always are said to approach cultural competence
but never achieve cultural competence.
In quantitative methods this is called an asymptotic function,
always approaching but never achieving and
this goes out to infinity.
The way I see this is that if you always approach something,
do things to work towards something and can never achieve
that thing, then that thing is unattainable.
The final problem is that there is a significant lack of
quantitative validation and also a reliable qualitative
replication related to outcomes with mental health and
disaster behavioral health services.
There is very little research and I can talk about
that later if there is a question related to that.
If I add the totality problem, the numbers problem,
the idealization problem, the lack of quantitative
validation and reliable qualitative replication, again
this, for me, makes cultural competence almost unattainable.
I don't want to give up on this concept because to me
cultural competence still yields a great unmet promise.
This type of honest and open discussion about the challenges
of the concepts to me seems to take us a little bit closer
towards the awareness that we need and to me the awareness is
our lack of cross cultural competence.
It is a starting point to talk about what needs to be done
rather than an ending point.
I offer this slide because Mike Tyson, former heavy weight
boxing champ was reported to have said that every boxer has
a strategy for each fight, until the first time
they get punched in the face.
This relates to me in terms of how we go about
our behavioral health response.
We go into action, we have our plan, our plan is backed up
by skills and experience, we are going to do our best and
then something new, something different, something totally
unexpected, life happens.
Even in these situations of life happening most
people, most of the time, get better.
In these times when we go into disaster response we have
our plan but I see our plan as classical music and that is
the formal way that we are taught to do disaster behavioral
health response and how we have been taught and
how we are prepared to do it.
The reality is that when we go into a disaster response
a lot of these things we take with us only when
they are ingrained within us.
Instead of playing classical music we are really dealing with
chord structures, or rhythm patterns, or melody.
Instead of playing classical music I think
we have to learn how to play jazz.
In order to play this we will start with an evidence base.
I want to say that this is different from
Dr. Indart's standard of an evidence-based practice
and the APA standard.
For me, I am including content knowledge and experience.
Experience can also include observations.
I think Dr. Indart did mention clinical experience with
one of her diagrams.
The evidence informs us that when we work with folks in the
immediate aftermath of disaster the response typically and
most effectively should be
focused at safety, security and comfort.
If we look at it in terms of Maslow's Hierarchy
we are not going to get very high initially.
A lot of that is going to be left for work later,
primarily by the individual who is going through and
who has made it through the disaster.
Another consideration, the content of working in the
aftermath of disaster with disaster victims is
the phases of recovery from disaster.
This diagram was taken from a number of studies,
a meta analysis of looking to see how in studies
people recover from disaster.
There are a couple of important parts here.
In the initial phases being present by
the responder is important.
In the continuing phases of disaster,
practical support is helpful.
Later, information and encouragement are helpful.
All of these while understanding that at
the end of the recovery process there will be
a new normal for the individual who is
going through the recovery.
There are two methods primarily used in responding to
disaster behavioral health in response.
One is, psychological first aid.
Psychological first aid is a manualized, evidence informed,
modular approach to help those affected by disaster and
it is intended to reduce initial distress to foster
adaptive functioning and to enhance coping.
After safety and security and emotional stability,
a lot of this is reconnecting to
the natural helping systems.
The second method of response is-- and more recently
developed-- is the skills for psychological recovery, SPR.
SPR is aimed at problem solving, planning for more
positive and meaningful activities, managing stress,
building and rebuilding healthy social relationships.
Both PFA, psychological first aid and SPR skills for
psychological recovery incorporate the benefit of
human resilience aimed toward recovery.
This is a combined term that we have been working with here
to get us a little bit closer to this notion of
cultural competence in quotation marks to get around
the limitations associated with cultural competence and also to
address many of the issues related to cultural awareness.
Remember, content knowledge and experience are irreplaceable
but at the same time and as Dr. Indart mentioned, they are
necessary, content knowledge and experience but not sufficient.
The bottom line for me is and has always been
whether any of this stuff works anyway.
To my thinking, strong content knowledge in disaster behavioral
health with an imbedded commitment to the inclusion of
inter and intra cultural perspectives is one way,
maybe a very important way to go.
I use the word perspective because if
we use perspective we can include specific evidence-based
theories and practices, we can also include
social constructs and we can include the principles that
Dr. Indart mentioned.
Including justice, including equity,
including beneficence and this term can be
more easily operationalized for
practical use than the broad terms and
board expectations of cultural competence.
This also includes cultural awareness.
We should still recognize that much of the work to support
cross cultural and content capabilities will be done
before a disaster ever occurs.
Sometimes it is important when you go into a disaster site
to do nothing because the folks who are there who you are
working with don't need that.
Human resilience is real.
Sometimes cultures dictate or indicate to us-- at least in
our observation of the cultural expressions-- that people don't
need any direct intervention but just be there in case they
do reach out to you but don't force anything.
Intercultural and intra cultural perspective require us
to do work inside out and outside in from looking at our
own biases and resistances to working in the context of others
and with the dynamics of difference that others have.
This is where we talk about awareness and knowledge and
other factors that the literature is important,
experience is important, lived experience is important and
cross cultural engagement really pays off.
In addition, there are a number of skills that
might be considered common factors.
Common factors is a term that was used back in the 1930s,
where they talked about the ability to establish
an alliance with an individual and the ability to engage
an individual emotionally.
Much of this would be a building block,
a foundation even, of common factors.
I think that ultimately we are going to find that a lot of
cultural competence, if we ever get there, to this
unattainable term is going to be at its root, competence.
Then there are the principles that Dr. Indart talked about,
which would include justice,
equity and beneficence, humility and respect.
We have the principles, social justice, equity,
beneficence, the social constructs, cultural, history,
politics, income levels and we have theories, dynamics of
difference, identity development, power, privilege,
micro aggressions, we have many of the building blocks of this
new thing that we will call cultural awareness or we will
call inter or intra cultural perspective and this can also
provide a greater measure of practical benefit and
interventions as they can be more easily operationalized and
measured more so than cultural competence.
I ask finally that you please not say that Kermit Crawford
killed cultural competence-- that is not my intention.
That couldn't be further from the truth.
I think as with many other things cultural competence is
very worthy and essential but it is challenged but so was
a rose bush, before a rose bush is cut back.
I know because I did that to the rose bush in my yard that
my wife planted and it is amazing this year after cutting
back some of the dead parts how much of the rose bush
actually comes back and how much a new rose bush comes through.
I also have faith that we will have a breakthrough if
we can talk about these things and how things are--
by slightly shifting the words I think even
this whole notion of cultural competence one day--
I will use the words of my man Isaac Hayes who would say and
this is by slightly shifting the words, let's not think of
cultural competence as running out of gas,
let's think of cultural competence as
saving its best for last.
And I'd be willing to entertain any questions.
Moderator: Thank you so much for you presentation Dr. Crawford.
We have two questions for you.
The first question is, How do you implement
cultural competency in the midst of a crisis?
Dr. Crawford: I think that cultural competence is really
worked out before you get to the crisis.
Sensitivity, we have human resilience going, everyone has
a history and has lived experience.
I think we bring all of those into a crisis but true
engagement, understanding, finding ways to understand
more about culture, understanding the questions that
we don't know that we don't know and pursing those
questions and those answers.
I think that would be the way to do it.
We can plan to go into a disaster setting and provide
a response as pretty as we want to be with everything that
we need to address the challenge.
As I said earlier, things are so different once you get there.
I had the privilege and awesome responsibility of being
director of the family assistance center on 9/11 and
as you know the planes flew out of Logan International
Airport here in Boston so I was there and we were there
when many other clinicians and
many other organizations providing services.
We had rehearsed this several years for such a disaster,
God forbid, but we had rehearsed it.
We had gone through it with many different professions
there and even going into that with all of the work that
we had done, the drills and everything else,
it was so different there would almost be
parts of it unrecognizable.
We were glad that we had done the work but a lot of
that certainly was contextual and situational that we had to
play jazz as we were there with what we already knew.
Moderator: Thank you Dr. Crawford.
Our next question is, How do you suggest agencies address
the cultural issues to develop outcome?
How do we know that our approaches
are reaching diverse populations?
Dr. Crawford: That question I would actually
answer in a different way.
It is very difficult when we talk about
cultural anything related to outcomes.
There have been a number of studies that have looked at
cultural responsivity or linguistic resource support
such as brochures in the language of the individuals
that are served or people who spoke the language or
speak the language and also who
share the culture of the individual.
There has even been assessment of cultural competence in many
different agency settings.
Until today there has not been a single-- to my knowledge--
outcome study that talks to the effectiveness of outcome of
cultural focused practices.
In my heart I know it is there and morally I know it is there
but as far as the science we don't have that yet.
The term cultural competence has been around since 1982 and
we are talking almost 30 years and we still don't have that.
The thing that I ask myself is that in all the time that
I have been working have I ever met anybody
who was culturally competent.
I can't say I have.
I am certainly not there and wouldn't be there.
With all of these considerations I would think that
an agency would have a long way to go.
There are things that an agency can do to put in place
to show that diversity is welcome, to show that there is
an understanding of different cultures, to show that there are
people there who represent the culture--
many of the things that Dr. Indart talked about.
As far as outcomes, the bottom line for me still is
are you making a positive difference in the lives of
the people who are coming in as in
Disaster Behavioral Health, are we making
a positive difference in the outcomes.
Moderator: Thank you for your presentation Dr. Crawford.
I would now like to introduce Ms. Almarie Ford.
Ms. Ford has over 30 years of experience in direct services,
human services administration,
program development and evaluation.
She has worked in the area of cultural and linguistic
competence for over 20 years, currently serving as
the Cultural Competence Officer for the Louisiana
Office of Behavioral Health through
hurricane Katrina and Rita.
Ms. Ford also supervises the SAMHSA system of care grant,
Louisiana Youth Enhanced Services.
She has also served as the Director of the City of
New Orleans Mayor's Office of Human Resources Policy and
Planning, overseeing the women's office, human rights office,
citizen action center, volunteers in government of
responsibility and the neighborhood planning office.
Please welcome Ms. Ford.
Ms. Ford: I would like to thank DTAC for the opportunity to
talk a little about field experiences and lessons learned
from one of the largest disasters in our country.
I am also privileged to be on this webinar with
Dr. Indart and Dr. Crawford and I have to publicly acknowledge
that Dr. Crawford was of great assistance to us in Louisiana
as were so many other national experts in the field.
Thanks again Dr. Crawford for all of your help.
I would like to look at disaster workers use of
cultural awareness values and principles and efforts
within survivor communities.
Disaster workers collaborate and network with survivor
communities to engage them in self-determination,
help to develop community capacity by assisting and
reestablishing rituals, culturally appropriate
anniversaries and commemorations,
setting specific meetings for disaster survivors to provide
information is important because many times information is
slow in getting to survivors.
Reporting transitional living community's success stories
give hope to other communities to help them
strive for their goals.
You must match the disaster workforce to
the cultural makeup of the environment which helps to
achieve local support and engage survivors.
This was a huge success in Louisiana with a large number of
survivor workers throughout the state.
Assertive outreach to community centers will help
to address early needs of survivors to help them accept
their transition community and be accepted.
This includes faith communities in all
education and human and social service agencies involvement
regarding ongoing needs.
You should inform transition communities of the cultures of
survivors residing in them and of their needs so that
they can try to appropriately assist them.
Development and implementation of specific culturally aware
projects and events to benefit survivors.
Specific support groups should be developed for survivors.
In Louisiana we used a number of different types of
names for stress management groups,
two that were named were Coffee Break for adults and
Juice Groups for children.
Just to mention another one or two, there was the
Quilting Queens group and there was a Coping Bingo for
the elderly group.
You need various types of groups for crisis counseling and
public education groups can be especially beneficial because
they may be the best way to get correct information to
survivors in a timely manner.
Community events that can be utilized to reach some
survivors include community fairs, festivals and other
types of community celebrations which Louisiana is famous for
but I think in other communities those things can also be used.
Interventions that boost and protect naturally occurring
social supports and build social skills and
neutral support are essential.
In New Orleans neighborhoods generally people look out for
each other and loan items to each other,
watch each other's children.
You want to keep folks moving in that direction
to help each other even though they have all of these
other problems going on.
You have to enhance capacity to solve problems in the transition
communities and you must reestablish people's
rhythm and routines and you must assess and address
vulnerabilities such as drinking and other substance use
which increase during disasters.
Disaster workers' engagement with individual survivors,
implementation of cultural and linguistically aware
individualized services will help people cope with
living arrangement with relatives,
living in extremely rural areas and trailers.
You can better assist survivors with the lack of
public transportation in those rural areas to be able to
get to grocery stores, drug stores or local
organizations to access resources.
In Louisiana we had to work with survivors on
the lack of food and some spices in grocery stores in
transition communities that were staples in
their diets in New Orleans.
As you know it is important that comfort foods are
available during this type of stress.
The lack of support systems because they are separated from
relatives and friends can cause issues such as
the elderly being placed in nursing homes and/or
senior apartments in the transition communities when
they have been living on their own prior to the disaster
because of their support systems.
Many people become homeless when they are moved to transition
communities due to the lack of family support.
Specifically, people who are
mentally ill and substance users.
We also found that some first responders that were
separated from their families and their usual work units to
help in remote locations experienced significant stress.
Youth and school and community adjustment issues,
teens and other children survivors may face cultural
issues such as dialect and slang used.
In Louisiana many transition community children dealt with
the fact that the new youth who were from other
cities by referring to them by their area codes which was
an insult and there were a number of fights and
problems around all of that.
You have to address disaster related issues with the youth
but also assist them in coping with stressors related
to discrimination about the previously mentioned issues.
In Louisiana we also found that lower income families were more
likely to have a child at risk for behavioral
disorders following the disaster so
attention in this area is needed.
Key lessons learned, in the communities specifically
disaster workers used cultural awareness to educate and
empower survivors to help emotional recovery.
You must be aware of the need to shift areas of emphasis
based on culture as survivors needs change
during each phase of recovery.
You can initially intensify your focus on survivors willing and
able to work on realistic and practical recovery plans
immediately and then intensify
your work with the other survivors.
You must establish culturally appropriate social networks and
partnerships for survivors as well as interventions and
referrals in transition communities, include culturally
appropriate mental health and substance abuse services
as well as faith healers and the faith community.
Recognition of ordinary citizen's acts of kindness
with whom various survivor communities
identify is very important.
In Louisiana we call them the unsung heroes.
The acknowledgment of community identified group leaders and
other indigenous people for their contributions to make
their communities and others proud and
give hope to survivors.
Key lessons learned around agencies involved.
Priority outreach to provide special programming for staff
who are survivors should be instituted to
take care of their emotional needs.
There is a need for staff with specialized training around
the issues faced by priority populations,
those who are mentally ill, homeless, etcetera as well as
general staff training and development regarding
responsiveness to phases of recovery.
Coordination and collaboration with the agencies in the
transitions communities is most important to try to provide
the most culturally aware services to the survivors.
Reemergence and stabilization of the public and private sector
infrastructure in the disaster communities with the assistance
of outside experts and consultants is important so
that creativity is used in rebuilding these systems.
You must build ongoing preparedness in recovery
planning, implementation and evaluation so that all
agencies and individuals will be constantly developing and
refining their plans and have drills on what to do to be
ready when future disasters occur.
Working with survivors who have their own stress
related to their losses must be more culturally aware of
the emotional financial and other needs of
the population receiving services.
The survivors working with others must focus on the
specific problems such as the lack of a job that
would cause these specific circumstances.
Disaster program administrative and managers need cultural
awareness regarding the disaster survivors who are
workers because they are extremely vulnerable to
emotional problems and compassion fatigue.
Special ongoing stress management activities are
necessary as well as sometimes changing the
workers' jobs to address this issue.
Key lessons learned regarding families,
individuals and those with special needs you can help
urban residents adjust to long term placement in rural areas by
addressing many of the issues already discussed and work
within the transition community to try to remove any stigma
related to the survivors being in that community.
In Louisiana there was the hurricane evacuee stigma which
caused many problems for people throughout the state.
Use strategies that are culturally accepted by minority
populations, that is another important thing we need to do.
You need in-depth information relevant to
specific survivor's cultures.
I think Dr. Crawford said this as well, do not assume that
everything you know about a race or culture applies to every
individual or family in that group.
If you ask the communities will help you with
strategies that are needed.
You must also help survivors close old,
non-viable options by providing new ones,
helping them get new ones.
You can help them establish different and/or new customs and
rituals and social relationships which will
help them achieve a sense of normalcy.
Some people cannot return to their original community
because of medical issues, because the infrastructure
issues are still around, you don't have all of the
medical institutions available, not enough doctors.
Due to these kinds of problems you have to help
the survivors to develop acceptable alternatives.
I think Dr. Crawford also mentioned the whole thing
about the new normal.
The key thing is you have to work with folks and specifically
the Gulf Coast, Louisiana and the New Orleans metro area
specifically has the new normal and the information that
I have provided for you are just a few of the important field
experiences and lessons learned that we were able to
present to you today but there are many more and
we hope to never have disasters to get the kind of
learning experiences that we have but then we do have to
appreciate that we have a lot of information available to us now.
Moderator: Thank you so much for your presentation Ms. Ford.
I have two questions for you.
The first one is, Are there any lessons learned about the cross
cultural issues in church supported family support
following relocations from shelters?
Ms. Ford: I would say there was a lot of that within
the state of Louisiana where folks were moved from shelters
through the help of church organizations and various
churches and I believe that overall they were very positive
experiences and one of the concerns was that the metro
New Orleans area is primarily Catholic and most of the rest of
our state is non-Catholic.
The work that was done was excellent work but the people
did not have the opportunity to worship in the religion that
they were most comfortable with at that time.
As far as the provision of food, shelter, clothing and
other kinds of resources that
were needed it was an excellent experience.
No matter the race or culture of the group of
the faith group that was providing services
we did not find any problems with that.
Cross culturally it worked well.
Moderator: Thank you so much.
Our second question is, What part of the community is
considered indigenous?
Ms. Ford: New Orleans-- in fact I believe the data says
approximately 70 percent of New Orleanians are lifelong and
that is what we consider indigenous because
they were born, raised and die here.
Moderator: Thank you so much Ms. Ford and thank you to
all of our presenters.
Before we conclude today's webinar we wanted to give you
the contact information for SAMHSA DTAC again.
Please feel free to contact SAMHSA DTAC at any time.
If you have any follow up questions or we were not able to
answer your questions during the webinar today
please contact the presenters via email,
their addresses are on the screen.
Thank you all for participating in the SAMHSA DTAC Applying
Cultural Awareness to Disaster Behavioral Health webinar.