Para mas información en espańol, vea la nota al calce. More than one in eight people in the United States are of Hispanic origin. The majority of children born in California are Latino. And yet, Latinos are falling through the cracks of the mental health system. As a caller on the program comments, "In my culture, in Mexico, going to a psychologist means I'm crazy, I'm loco." This week: we go Between Two Worlds, to investigate Mental Healthcare for Latinos. Language is often a barrier. Dr. Roberto Lewis-Fernández, a psychiatrist at Columbia University says, "If someone thinks they're being attacked spiritually, you have to begin with an understanding of that language." Almost a third of all Latinos lack health insurance. As Alba Cuevas, who suffers from depression, puts it, "All they can do is stay at home and hope they'll get better by themselves." What needs to change? We'll visit a program in Dallas that works -- patients NEVER miss their appointments. Plus, we'll talk to Elena Avila, a curandera, or traditional folk healer, who tackles depression with rituals: "I finish with the rosemary that I pass all over the body, and the last thing I do is I pass the eagle feather or the condor feather." And writer Judith Ortiz Cofer discusses her new novel, a coming-of-age tale set in her native Puerto Rico, and describes how her own family dealt with her father's depression. Host Dr. Fred Goodwin begins with an essay in which he says there is a lot we can learn from one of our guests today, who is not only a psychiatric nurse, but also a folk healer, a tradition that has been central to Latino cultures for centuries. She points out that understanding the patient's story is critical to her ability to help people. In today's managed care environment, he says, procedures and tests are valued more than the clinician's time, and the principle casualty of this is that we miss the patient's story -- not the symptoms that they present, not our differential diagnosis, not even our preliminary treatment plan. If we miss the patient's story -- what's really going on in his or her life -- we may miss the opportunity to heal. We then hear a firsthand account. The Infinite Mind's Marit Haahr speaks with Alba Cuevas. She was born in Santa Domingo and moved to the United States ten years ago. She suffers from depression and PTSD, and for almost a year she has been going to the Hispanic Treatment Program at The New York State Psychiatric Institute. Ms. Cuevas considers herself lucky to have found and been accepted to this clinic -- it's part of a research institute, so services are free. Translation is provided by her psychiatrist, Dr. Cesar Alfonso. Ms. Cuevas says she first realized something was wrong because she felt confused, she'd misplace things or get lost, and she felt overwhelming loneliness. Now, she says she feels comfortable. She can sleep better, her appetite is normal, she's less confused, and she values life again, when before she had lost the sense of hope and had thought of jumping off the fourth floor to kill self. She has only told one of her children, her son, about her treatment and medication. She hasn't told more people because, she says, some people discriminate. They don't think you can get better; they think you can go crazy or are crazy if you take medication. In Santa Domingo, she says, almost everyone believes you must be crazy to take medication, and because there is very limited access to treatment, a lot of people don't get better, which just feeds into notion that people will remain crazy. Down there, she says, all people can do is go to the public hospital, and even then, they may not get diagnosed or treated. And here, a lot of people don't have insurance, so they can only stay at home and hope they get better by themselves. Latinos are the largest and fastest growing minority population in the United States. They're at high risk for depression and other mental illnesses. But they face some of the most severe barriers to adequate mental health care. What needs to change? Later in the show, we speak with psychiatrist Dr. Roberto Lewis-Fernández and Elena Avila, who is curandera, or traditional Mexican folk healer. But, before we do, we offer some insight into what a curandera does. Reporter Carol Boss visited Elena Avila where she lives and works in Albuquerque, New Mexico. Her report, excerpted here, originally aired on public radio station KUNM. Ms. Avila walks us through three major elements of curanderismo -- the platica, a deep heart-to-heart talk that continues for as long as it needs to (hours, days, weeks, months); the limpia, a ceremony for spiritual cleansing (the ceremony she describes uses resin from a tree, rosemary, raw egg, and an eagle feather); and the soul retrieval, a treatment to heal susto or "soul loss", which, she explains, can happen as the result of trauma. Then, Dr. Goodwin is joined by Elena Avila. In addition to being a professional curandera, or folk healer, Ms. Avila is also a psychiatric nurse and the author of Woman Who Glows in the Dark. Also joining them is Dr. Roberto Lewis-Fernández, associate professor of psychiatry at Columbia University and director of the Hispanic Treatment Program at the New York State Psychiatric Institute. Dr. Lewis-Fernández begins by describing some of the barriers to good mental health care for Latinos. These include finding affordable health care, since there is an insurance gap by ethnicity; issues of presentation, that is, illnesses may be presented in ways or in settings where clinicians are unable or unwilling to recognize psychopathology, such as in primary care; language; and stigma. He adds that, curiously, recently arrived migrants show lower rates of psychopathology then those who have lived here longer or been born here (a point we come back to later). Ms. Avila adds that there are also cultural beliefs that can impede care; for example, some people believe illnesses result from hexes or curses. She does not believe in these things and sees part of her role as to educate those who come to her. They then discuss some of the variations and similarities in the many different groups that make up "Latinos." Dr. Lewis-Fernández says that, despite many, many differences, there are some things that do make it worthwhile to look at all these cultures together, such as, generally speaking, a belief in the importance of family and some common ways of expressing illness. However, physicians should be careful not to stereotype. One way that many Latinos talk about illness is using the language of nervios, or nerves. Ataques de nervios is also very important, says Dr. Lewis-Fernández. These are nervous experiences which the person holds in until he or she blows up in a fit of emotionality, and then contains again. They often occur in response to something terrible in the person's life, and they are frequently misdiagnosed. Ms. Avila says one of the reasons she left western medicine was that she wanted to be able to listen to her patients for as long as was needed, so that she could treat the whole person, and not just the diagnosis. In curanderismo, there is no severing of body and mind. She spends a lot of time just listening to the patient's story, so, together, they can come up with a diagnosis, and then a treatment that will work. She believes in integrative medicine, which means sometimes she refers the patient to a psychiatrist or an acupuncturist, for example. Dr. Goodwin then asks Dr. Lewis-Fernández how this differs from what they do as psychiatrists. He says that he is sorry to say that one difference is that Ms. Avila has time to listen for a story. Unfortunately, in busy emergency rooms, conditions can become too quickly medicalized into things they look like. Often the story is left behind, and the person is catalogued with a diagnosis that may be wrong -- for example equating ataques de nervios with panic attacks or even psychosis, in cases where the person may talk about seeing or hearing things (in a metaphorical sense, which might get translated literally). They then hear from a caller, Vicente from Atlanta. He says he has depression, but, at first, he didn't know what it was, and he went to the doctor because he thought it was a physical problem. After several visits, the doctor suggested he see a psychologist. Vicente says that in his culture, going to psychologist means you're crazy, you're loco. When his problems persisted, he decided to go, anyway, and it's helping him a lot. He adds, however, that it's difficult to afford because you need good health insurance. Luckily, he found a psychologist in his community who only charges what people can afford to pay. Dr. Goodwin comments that he traded one problem for another -- stigma for access issues -- until he found a therapist who would work on what's called a sliding scale. After a short break, they take another call, from Ariceli in New Jersey. She, too has depression. She says that in Mexico, she participated in platicas and went to a psychologist. She adds that in the United States, she believes differences in language and problems with acculturation can lead to depression. Dr. Lewis-Fernández says that, curiously enough, as he mentioned earlier, there are actually lower rates of disorder in migrants than in people who have lived here a long time or been born here. He says this may have something to do with the hope that migrants have when they come here -- they may have a willingness to suffer through problems without breaking down, because they are set on an improvement. Dr Goodwin asks if it could also be protective that they are probably still embedded in a traditional family structure . Dr. Lewis-Fernández says family can definitely have protective effects, although some families can actually be damaging. Ms. Avila says this is why she always like to include the whole family in treatment, since, for example, there are cases where a child may have schizophrenia and clearly needs psychiatric treatment, but the father thinks his son's just being weak or lazy. She adds that there are many people who may try to take advantage of this sort of belief -- charlatans or impostors who take vast sums of money from the family. They are not true curanderos, and people need to be educated about them. Dr. Lewis-Fernández says one of the problems is stigma. Even when a true curandera or primary care physician or priest suggests that going to a psychiatrist or psychologist may be necessary, there can still be resistance. Dr. Goodwin then asks Dr. Lewis-Fernández whether he's seen the benefit of the combination of approaches, that is, mainstream American medicine and folk healing. He answers that it can be very beneficial. It's a matter of understanding the language people use. If someone says he has experiences that lead him to think he's being attacked spiritually by others, the person treating him needs to understand that language. Simply saying, "No, I don't believe that. Take this pill," won't work. They then discuss actual language issues, and the problems that can occur when mental health providers do not speak Spanish. Dr. Lewis-Fernández says all too often non-professionals are used to translate, and this is a major "don't." Doctors sometimes bring in any Spanish speaking person in the hospital, or even ask a child to translate. This is terrible -- confidentiality is at risk, the quality of the translation is varied, and the patient may be unwilling to disclose what's really going on in the presence of a stranger or child. They conclude by talking about the things that need to change in the mental healthcare system so that Latinos no longer fall through the cracks. Dr. Lewis-Fernández says access must be improved, in both insurance and language, there must be outreach to overcome stigma, and, within the medical system, there must be greater integration of mind and body to meet the expectations and concerns of Latino patients. Ms. Avila adds that soul and spirit should always be included, and healers and psychiatrists should work together more so they can truly be of service to others. To contact Dr. Lewis-Fernández, please write to: Dr. Roberto Lewis-Fernández, Director, Hispanic Treatment Program, New York State Psychiatric Institute, Unit 69, 1051 Riverside Drive, New York, NY 10032. Or visit http://www.nyspi.cpmc.columbia.edu/. To contact Elena Avila, please visit http://www.elena-curandera.com/. To order Woman Who Glows in the Dark, click here. School counselors have long claimed that a student's suffering grades may stem from family and personal problems, not the child's failure to grasp the lesson. In Dallas, Texas, the school district has been addressing this concern for years, by offering free, school-based health, and especially, mental health care to its mostly Hispanic and African American students and families. More than half the districts' 160,000 students are Hispanic, and the services offered are tailored to the community. Research shows the program works, and the President New Freedom Commission on Mental Health recently singled it out as a model for school districts across the country. Bill Zeeble reports from Dallas. Nine Youth and Family Centers serve the 218 schools in the sprawling Dallas public school system. The staff at each mental health clinic includes professional counselors, child psychiatrists, psychologists, marriage and family therapists, social workers, and nurses. Each child is evaluated by a clinician, who works with the child, his or her family, the teacher and the principal to map a treatment. Most are diagnosed with behavioral or mood disorders. Medication is eventually prescribed for about one in five. Research shows great improvements shared by most students receiving these behavioral and mental health services. Recent statistics show disciplinary referrals dropped 85% for students going to the clinics, compared to when they weren't. Absenteeism dropped by half. Perhaps the most remarkable statistic is that patients keep their appointment 100% of the time -- that's double the rate at community mental health centers in Dallas. child psychiatrist Dr. Leonora Stevens says she thinks the compliance rate is so high because the clinics are in the schools and aren't branded as being specifically for mental health, "There's not a stigma, when you walk through this door, that you must have a mental problem. You might come in for immunizations. It's really opened that up to our families in the community to be able to come here." Jenni Jennings, Executive Director of the Youth and Family Centers, says even when parents are unfamiliar with mental health services, or believe seeing a psychiatrist means you're crazy, they'll do anything to help their children do better in school. It also helps that 70% of Jennings' staff is Hispanic or African American and many are bilingual: "There are many issues -- adjusting to a new culture, a new school system -- so families embrace and welcome someone who gives them help." Dulce Torres, who manages one of the nine Youth and Family Centers, says there are other, basic ways they've made the Centers welcoming to their Hispanic clients. Rooms are decorated with flags, statues, and pottery from Mexico and Central America, and with posters of works by Latino artists. And families are always interviewed together, since family is so important in Latin cultures. The in-school health and mental health care carries no fees and requires no insurance for families - many of whom don't have any. Immigration status is never an issue. The program is paid for by the Dallas Independent School District, which gives $3.5 million a year, and Parkland County Hospital, which provides another $1.5 million. To read more about why the President's New Freedom Commission on Mental Health has singled out this program, please visit: http://www.mentalhealthcommission.gov/. Family is absolutely central in Latin cultures. So, what happens when someone in your family has major mental illness? Dr. Goodwin speaks with writer Judith Ortiz Cofer, who was born in Puerto Rico. She's a poet, essayist and novelist, and a professor of English at the University of Georgia. In her most recent novel, The Meaning of Consuelo, one of the main characters suffers from schizophrenia. She discusses this and her own family's reaction to her father's struggles with major depression. Ms. Ortiz Cofer says her father's "sadness" was a topic of conversation in her family, but it was not labeled an illness until he had to decide whether or not to take a medical leave from the Navy. Her family tended to blame his "changes" on his being deprived of his language and culture while he was on board the ship; they saw it not as a medical illness, but as a deficiency that they needed to make up. She then reads a passage from The Meaning of Consuelo. In the book, the title character's sister, Mili, is starting to disappear into her own world. In this passage, Mili and Consuelo's mother consults her own mother about what to do. The grandmother, Abuela, in turn channels her mother, Mama Isadora, for advice. Abuela refuses to entertain the possibility that Mili could be sick or "loco." Consuelo questions her mother's and grandmother's way of handling the problem; she thinks perhaps her father is right -- Mili should see a doctor on the mainland. Dr. Goodwin asks Ms. Ortiz Cofer whether there are parallels with her own family. She says there are -- whenever her father went with the fleet for six months to Europe, her mother would move her from New Jersey back to Puerto Rico. There, she would eavesdrop as her mother would ask all her relatives what to do about her husband's sadness, and they would draw on family stories and legends to help her. She believes her mother was somehow empowered by this, and it helped her deal with her husband's depression, at least for a while. To contact Ms. Ortiz Cofer, please write to: Judith Ortiz Cofer, Franklin Professor of English and Creative Writing, Department of English, University of Georgia, Athens, GA 30602. Or visit http://www.uga.edu/. To order The Meaning of Consuelo, click here. Para mas información, puedes contactar: Especialistas Bilingues de Su Familia se refiere a uno o más de 16,000 provedores de salud local, incluyendo centros de salud y migratrorios de la comunidad. Las personas qué llaman también pueden pedir información básica de salud, consultas para lugares de información o recibir manuales de datos bilingües para los clientes. Manueles se pueden obtener presentmente en una variedad de tópicos, incluyendo: asma, cáncer, analizando enfermedades cardio-vasculares, imunizaciones para niños y adultos, diabetis, violencia doméstica y HIV/AIDS. "Su Familia" es apoyada por HHA Recursos de Salud y Servicios de Administración y HHS La Oficina de Salud para Minorías y es desarroyada y operada por La Alianz Nacional para La Salud de Los Hispanos. La linea de ayuda con número gratis está abierta de Lunas a Viernes, 9 a.m. a las 6 p.m. tiempo Este.
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BETWEEN TWO WORLDS: MENTAL HEALTHCARE FOR LATINOS
Week of October 20, 2004
Su Familia bilingual information specialists refer callers to one of more than 16,000 local health providers, including community and migrant health centers. Callers can also request basic health information,
referrals to information sources, or receive consumer- friendly, bilingual Su Familia fact sheets. Fact sheets are currently available for a variety of topics including: asthma, cancer screening, cardiovascular disease, child and adult immunizations, diabetes, domestic violence and HIV/AIDS.
Su Familia is supported by HHS' Health Resources and Services Administration and HHS' Office of Minority Health, and was developed and is operated by the National Alliance for Hispanic Health. The toll-free helpline is open Monday through Friday, 9 a.m. to 6 p.m. Eastern Time.
"Su Familia" Tommy Thompson Secretario del Departamento de Salud y Servicios Humanos ha anunciado la creación de la linea de ayuda "Su Familia" Salud de Familia Nacional Hispánica (866-783-2645/866-SU-FAMILIA" para ayudar familias Hispanicas obtener lnformación de salud basica para ayudarles a prevenir y manejar condiciones crónicas y referirlos a provedores locales de salud y programas apoyados federalmente incluyendo el Program de Niños Estatal de Aseguranza de Salud.