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LIFE IS PRECIOUS:A PROMISING COMMUNITY DEFINED EVIDENCE

PRACTICE-BASED MODEL

ROSA M. GIL, DSWFOUNDER, PRESIDENT & CEO

ROUND TABLE DISCUSSION – LATINA TEEN SUICIDE SPONSORED BY NEW YORK STATE COALTION FOR CHILDREN’S MENTAL HEALTH SERVICES. FEBRUARY 7, 2011, ALBANY, NEW YORK

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COMUNILIFE, INC.

WHO WE ARE Comunilife is a Latino multi-service, not-for-profit organization

created in 1989 to expand access to the continuum of housing, behavioral health and social services for Latinos and other diverse communities in New York City.

Comunilife Pioneered the Multicultural Relational Approach for Diverse Populations™ that is based on a community-centered practice that incorporates the worldview, cultural values, beliefs and endemic knowledge in the definition, assessment, treatment interventions of behavioral health problems with Latinos. (Gil & Genijovich, 1994) 2

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COMUNILIFE, INC. (CONTINUED)

WHO WE ARE Comunilife developed the Multicultural Relational

Assessment Instrument™ to enable clinicians to incorporate clients’ cultural knowledge and concerns into treatment interventions, treatment plans that includes goals, objectives and outcomes. (Gil & Genijovich, 1994)

Life is Precious, a suicide prevention program for Latina adolescents was developed based on the principles of the Multicultural Relational Approach for Divers Populations™. It is a promising community-defined evidence based practice to be discussed later in this presentation. (Gil, Rendon & Cifre, 2007)

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Hispanic Disparities in Mental Health Care and Research

Disparities in mental health care for Latinos and other multicultural populations are greater in comparison to white populations. The inequalities are more prevalent in the areas of access, availability, quality and outcome of care. (Callejas and Martinez, 2009)

Collectively, ethnically/racially diverse populations experience a greater disability burden from emotional and behavioral disorders than do white populations (Huang, 2002: Department of Health and Human Services, 2001)

Between 1986 and 2001, nearly 10,000 participants were included in randomized controlled trials evaluating the efficacy of interventions for four mental health conditions (bipolar disorder, schizophrenia, depression and ADHD) and included only:

■ 561 African Americans (5.6%)■ 99 Latinos (.01%)■ 11 Asian American and Pacific Islanders (.001%)■ No single study analyzed the efficacy of the treatment by

ethnicity or race. (Miranda et al, 2003)4

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Current Evidence-Based Practice (EBP) In an attempt to provide the best treatment available, policymakers,

researchers and funders have promoted the use of evidence-based practice (EBP)

But, is the EBP “Gold Standard” culturally appropriate?

■ Most EBP trials are conducted with White, educated, verbal and middle class individuals and may not generalize to ethnic/racial groups and third world communities (Bernal & Sharon-del-Rio, 2001)

■ Empiricism (upon which randomized-controlled trials are based) is a western epistemological model–does not support other knowledge bases. (Callejas and Martinez, 2009).

■ Frequently don’t take the following aspects into consideration:

◆ Historical trauma ◆ Cultural values, beliefs, traditions and preferences◆ Contextual, transactional and societal variables relating to the

environment in which the individuals lives.

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Current Evidence-Based Practice (EBP) (Continued)

“The central problem is that treatments that have been validated in efficacy studies cannot be assumed to be effective when implemented under routine practice conditions” (Hoagwood et al., 2001).

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An Alternative Community-Defined Evidence (CDE)

The Community Defined Evidence Project CDEP, a partnership between the National Latino Behavioral Health Association (NLBHA) and the National Network to Eliminate Disparities (NNED) in Behavioral Health. (NNED, 2007)

Community-defined evidence (CDE) is a set of practices that communities have used and determined to yield positive results as determined by community consensus over time and which may or may not have been measured empirically but have reached a level of acceptance by the community (Martinez, 2008)

CDE includes worldview, historical and contextual aspects, and transactions processes that are culturally rooted and do not limit to one manualized treatment

Emphasize the importance of community input in development, implementation and evaluation of practices.

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An Alternative Community-Defined Evidence (CDE) (Continued)

The central goal of the CDEP is to discover and develop a model for establishing an evidence based using cultural and/or community indices that identify community-defined and based practices that work.

CDEP was designed to identify “successful” community defined-based practices to support overall good health and well-being among Latinos.

With the support of SAMSHA the University of South Florida in partnership with NLBHA and NNED has conducted research of community defined-based practices in 16 Hispanic agencies throughout the country.

Comunilife’s Life Is Precious program, grounded on our Multicultural Relational Approach for Diverse Populations™ has been selected as one of the CDE practice in the University of South Florida’s research study.

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DEFINITION OF THE PROBLEM

Latina adolescents are much more likely than black and white adolescents to report attempt suicide (CDC YRBS, 2009) in the nation.

New York City Latina adolescents have suicide attempt rates that are higher than the national average (11% versus 14.7%).

Latina teens generally attempt suicide at a rates far greater than their non-Hispanic counterparts –more than twice the rate of white youth in New York City (14.7% versus 6.2%) and 44% more frequently than teenage African-American girls (14.7% versus (10.2%).

More than one Latina teenager out of every five living in Brooklyn attempted suicide during 2009 –a rate that was almost twice the level just two years earlier. Brooklyn has the highest rate of attempts suicide by Latina teen than any other locality in the country.

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The levels of suicide attempts by Latina teenagers were also shockingly high in the City’s other boroughs: 16.5% in Staten Island, 15.3% in the Bronx, 12.2% in Queens and 11.7% in Manhattan.

This mental health disparities have been neglected by policy makers and researchers since 1995 “CDC RBS, 1995”.

Central and South American and Caribbean countries had some of the lowest suicide rates in the world (Carpinello, 2006)

Lack of research on efficacy of Latino community defined practice based models of care.

Most current clinical practices not normed on Latino populations.

Failure of traditional treatment programs due to a poor fit with Latino community.

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LIFE IS PRECIOUS

DEVELOPMENT OF A COMMUNITY DEFINED PRACTICE-BASED MODEL

Mobilized the following sectors to create awareness, education and actions to address the problem:

◆ Latino and English Speaking media

◆ Latino business community

◆ Latino and non elected officials ◆ Latino Grass root organizations ◆ Government Agencies ◆ Latino and Non-Latino mental health providers ◆ Community at large

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Conducted a qualitative marketing research focused on Latino parents and teens in the Bronx with the following research objectives:

to assess awareness and attitudes towards teen suicide and prevention to determine awareness of existing resources and programs to better understand the target population’s lifestyles and preferences to seek suggestions for program design to address Latina teen suicide

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QUALITATIVE MARKETING RESEARCH FINDINGS

Huge communication gap between Latina adolescents and parents driven by acculturation stress and immigration

Adolescents believe that their worries and problems could lead to suicide; parents do not believe so.

Cultural differences increase stress and can play a role in suicide ideation and attempts.

Daughters’ increased independence is perceived as “falta de respeto”. Respect is a major Latino cultural value (Gil & Vazquez, 1996)

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Adolescents identify family members as role models but do not seek their help due to lack of confidentiality in the family.

Parents usually turn to family for help and to mental health services only as a last resort.

Parents and adolescents shared a strong anti-medication bias for treating emotional distress.

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QUALITATIVE MARKETING RESEARCH FINDINGS(CONTINUED)

Parents and adolescents do not believe that traditional mental health services and schools are responsive to their needs.

Parents and adolescents are UNAWARE of suicide prevention programs or suicide hotlines in English or Spanish.

Adolescents communicate through “My Space.”

Adolescents suggest programmatic activities; peer counselors; academic tutoring and internet café “fun” activities such as discovering their talents.

Mothers suggest activities to foster socialization to decrease their sense of isolation.

Mother suggested family oriented activities. 15

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LIFE IS PRECIOUS

GOALS AND OBJECTIVES: Decrease suicidal behavior Improve communication between parents and adolescents

Improve academic performance

Increase self-esteem

Improve social relationships

CRETERIA FOR ADMISSION: Latina teens between 12 and 16 years old In treatment in a mental health clinic Diagnosis of mood disorder with hx of suicidal ideation or

attempts Must be in school

PROGRAM HOURS Monday through Friday 3:30 PM to 7:30 PM Saturdays 10 AM to 2 PM

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Locations

Bronx Program open in 2008 (6 days a week) Brooklyn Program open in 2009 (3 days a week)

PROGRAM ACTIVITIES

Tertulias for mothers and Dominos for fathers Saturday’s family day Creative art therapy Tutoring Youth ambassadors (peer mentors) - (Promotores de Salud Mental) Internet café School advocacy Case management to help families with socio economic stressors Indigenous volunteers, “madrinas”, “padrinos” and youth

ambassadors (Promotores de Salud Mental) Community coalition to reduce suicide among Latina adolescents

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PROGRAM OUTCOMES

More than 100 Latina adolescents have participated in the program in the last two years.

Decreased suicidality only 5 teens were readmitted during the two years of the program in the Bronx. .

Strengthened family communications and relationships with mothers, friends and others.

Sixty six percent (66%) of the girls improved academic performance

Forty four percent (44%) of parents agreed teens had better coping skills; and 86% of girls felt they handled their daily lives better than they used to

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PROGRAM OUTCOMES (CONTINUE)

Adolescents discovered personal talents, improved self-esteem and increased optimism about life.

Level of satisfaction by participants indicates this model is culturally appropriate for parents and adolescents

Twenty eight (28) “padrinos”, “madrinas” and youth ambassadors participated in the program (Promotores de Salud Mental)

Lack of research resources to analyze all the data collected in the Life Is Precious program.

Program is funded by New York Community Trust; Van Ameringen Foundation and New York State Office of Mental Health

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References CitedBernal, G. & Sharon-del-Rio, M.R. (2001). Are empirically supported

treatments valid for ethnic minorities? Toward an alternative approach for treatment research. Cultural Diversity and Ethnic Minority Psychology, 7: 328-342.

Carpinello, S. (2006). Suicide in 2 Ethnic Groups is Topic at Assembly Hearing. New York Times, December 8, 2006

Gil, R. & Genijovich, E. (1994). The Multicultural Relational Approach for Diverse Populations™. Comunilife, Inc.

Gil, R. & Genijovich, E. (1994). The Multicultural Assessment Form. Comunilife, Inc.

Gil, R. M. & Vazquez, C. (1996). The Maria Paradox. G.P. Putnam’s Sons, New York, NY

Gil, R., Rendon, M. & Cifre, R. (2007). Life is Precious. Comunilife, Inc.Hoagwood, K., et al. (2001). Evidence-based practice in child and adolescent

mental health services. Psychiatric Services, 52:1179-1189. Huang, L. (2002). Reflecting on cultural competence: A need for renewed

urgency. Focal Point, 16 , 4-7.

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References Cited (Continued)

Miranda, J., Nakamura, R., & Bernal, G. (2003). Including ethnic minorities in mental health intervention research: A practical approach to a long-standing problem, Culture, Medicine & Psychiatry, 27 , 467-486.

U.S. Department of Health and Human Services .(2001). Mental health: Culture, race, and ethnicity – A supplement to mental health: A report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services.