Transcript Slides D6a

Session # D6a
Planning to check out poster presentations in
between sessions?
See below for posters related to this session:
1.) Coping styles predict poor health related quality of life (HRQOL) in rural Appalachians (Friday Only)
Authors: Shannon Beish, M.A., Penny Koontz, Psy.D., April Fugett, PhD, Marshall University, Emily Selby-Nelson, Psy.D., Cabin
Creek Health System, Alyssa Frye, M.A., Marshall University
CFHA 18th Annual Conference
October 13-15, 2016  Charlotte, NC U.S.A.
Session # D6a
“Crying after the sun goes down”:
Caring for Karen families using cultural case formulation
of integrated medical, behavioral, and complementary
and alternative medicine in primary care
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Melanie Martin-Peele, MA, MEd, Family Therapist
Jacqueline Guajardo, MA, PhD, Director of Behavioral Health and Assistant Professor
Mary P. Guerrera, MD, Director of Integrative Medicine and Professor
Christine M. Abdelsayed, MD, Physician
CFHA 18th Annual Conference
October 13-15, 2016  Charlotte, NC U.S.A.
Faculty Disclosure
The presenters of this session have NOT had any relevant
financial relationships during the past 12 months.
Learning Objectives
At the conclusion of this session, the participant will be able to:
• Explore the use of cultural case formulation to
deliver integrated medical, behavioral, and
complementary and alternative medical care
• Identify the unique cultural and biopsychosocial
needs of Karen refugees in the US
• Apply cultural case formulation to medical,
behavioral, and complementary and alternative
medicine integrated primary care model in one
practice using a case study
Selected Bibliography/Reference
1)
Oleson H, Chute S, O’Fallon A, & Sherwood N. (2012). Health and healing: Traditional medicine and the
Karen experience. Journal of Cultural Diversity, 19, 44-49.
2) Davis WW, Mullany LC, Schissler M, Albert S, & Beyrer C. (2015). Militarization, human rights violations
and community responses as determinants of health in southeastern Myanmar: results of a cluster
survey. Conflict and Health, 9:32. DOI 10.1186/s13031-015-0059-0
3) Kirmayer LJ, Rousseau C, Rosenberg E, Clarke H, Saucier JF, Sterlin C, Jimenez V, & Latimer E. Cultural
assessment tool from Report on the evaluation of a cultural consultation service in mental health. McGill
University Division of Social and Transcultural Psychiatry. Retrieved March 11, 2016 from
http://www.mcgill.ca/tcpsych/publications/report/appendices/handbook/assessment/
4) Helms, JM, Walkowski SA, Elkiss M, Pittman D, Kouchis NS, & Lawrence B. (2011). HMI Auricular Trauma
Protocol: An Acupuncture Approach for Trauma Spectrum Symptoms. Medical Acupuncture, 23:4, 209213. DOI: 10.1089/acu.2011.0859
5) Vickers A J & Linde K. (2014). Acupuncture for Chronic Pain. JAMA, 311:9, 955-956.
6) Spradley JP. (1979). The Ethnographic Interview. Belmont, CA: Wadsworth.
7) American Psychiatric Association. (1994). Diagnostic and statistical
manual of mental disorders (4th ed., text rev.). Washington, DC: Author.
8) American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).
Washington, DC: Author.
9) Mezzich et al. (2009). Cultural Formulation Guidelines, Transcultural Psychiatry September, 46: 383-405.
10) New York City Department of Mental Health and Mental Hygiene. (2007).
https://www.mcgill.ca/iccc/files/iccc/Interview.pdf
11) Brief Cultural Interview. Retrieved from http://www.multiculturalmentalhealth.ca/clinical-tools/culturalformulation/
12) Neiman, Soh, Sutan. (2008). Karen Cultural Profile. https://ethnomed.org/culture/karen/karen-culturalprofile
Learning Assessment
A learning assessment is required for CE credit.
A question and answer period will be conducted
at the end of this presentation.
Cultural Case
Formulation
for Health
Professionals
Karen grandmother and grandson in Waterbury, CT, 2014
http://falcetti.photoshelter.com/image/I0000HIadqze8En8
“I want to understand the world from your point of view. I
want to know what you know in the way you know it.”
Spradley (1979, p. 34)
Cultural Case Formulation
for Health Professionals
• Provides a framework with sample questions, and engagement
strategies to guide patient interviews;
• Considers the impact of social, cultural, and political forces on the
expression and evaluation of disease, health, and health behaviors;
• May be used as a complement to the medical history and physical
interview;
• May be used when attempting to diagnose in multi-cultural care
environments;
• Indicated when health professionals and patients have different
socio-cultural backgrounds.
8 Areas for Exploration:
Overall cultural assessment
regarding diagnosis and care
1. Ethic/Cultural identity of the person
2. Language preference/competence
3. Cultural explanations of illness
4. Use of culturally prescribed/sanctioned
medicine or practices
5. Cultural factors related to psychosocial
/familial environment and levels of
functioning
6. Immigration/Migration History
7. Trauma history and impact
8. Cultural elements of the relationship between
the individual and the clinician
Sample Questions to Assess
Cultural Explanation of Illness
and Treatment
• What words do you usually use when you
talk with your family, relatives or friends
about your problem/sickness/pain?
• What do you or others in your community
or family think could be the cause of your
problem/sickness/pain?
• What sort of help and treatment do you
want?
• What sort of help and treatment have you
tried?
• If you had stayed in your country of origin,
what sort of help and treatment would you
have asked for there?
Opening case questions
1. Is this a case of an identifiable cultural condition?
2. How is her experience related to her dislocation and grieving
process?
3. What is her experience with her host culture and how does it affect
her health and well-being (i.e., lack of language supports)?
4. If she had stayed in Burma/Thailand, what sort of help and
treatment would she have asked for?
•
What complementary and alternative treatments can we offer her in
our office?
Karen People
Photo sources:
https://www.mprnews.org/story/2010/01/11/karen-myanmarburma-new-year
http://karennews.org/photo/life-in-ei-tu-hta-idp-camp/
http://karennews.org/photo/striving-for-a-decent-education/
Karen People
Photo sources:
https://goo.gl/maps/McEpVhUkGLs
http://www.unhcr.org/enus/news/stories/2012/2/4f2be55e9/karenskentucky-find-new-life-challenging.html
http://courantblogs.com/photo/2013/08/refu
gee-community-takes-root-in-hartford/
http://ctapaac.com/2014/07/commonharvest-brings-togehter-suffield-farmers-andhartfords-karen-community/
http://arthurnazaryan.wix.com/ok#!photosta
ckergallery0=7
http://www.catholictranscript.org/about/191news/latest/763-eleven-karen-peopleconfirmed-at-last.html
Case Presentation
Patient: 53 y.o. Karen speaking female originally from Burma, presents to office for “pain
all over her body.”
Chief complaints: pain in eyes, facial pain, all-over body pain, back pain, left chest pain
Additional later complaints include bilateral arm pain, leg pain, epigastric pain, joint pains,
depression, fatigue, difficulty concentrating, decreased appetite, and poor sleep. She
reports delivering her last child during the rainy season, and believes she is now cursed
with chronic pain for the rest of her life. She states this has happened to many of her
friends.
PSHx: Uterine surgery (? Hysterectomy) for “grapes in the uterus” (PE showed no
evidence of cervix, US confirmed presence of one ovary with cyst)
Allergies: None
Diagnoses and Medication
Current Diagnoses
Fibromyalgia
Chronic pain
Obstructive Sleep Apnea
Depression due to medical condition
H pylori infection
Upper gastric and RUQ pain
Back pain
Insomnia
Subclinical hypothyroidism
Other abdominal pain
Health maintenance
Medications at initial visit
Ibuprofen, duloxetine
Current medications
Acetaminophen, vitamin D, duloxetine, lactulose,
lidocaine patch, lorazepam
• Also uses Tiger Balm, menthol nasal inhaler
Discontinued (Tried) medications
Gabapentin, pregabalin, milnacipran,
amitriptyline, escitalopram
Referrals
Rheumatology, Pulmonology (OSA), Physical
Therapy, Behavioral Health, Acupuncture
Behavioral Health Assessment
Areas of concern
• Dislocation trauma (7 years at refugee camp in Thailand (2006-2013), 3 years in US (2013present))
• Past and current suicidal and NSSI ideation; plan, intent and gesture were denied.
• Depressed and hopeless mood with congruent affect.
Symptoms at assessment
Difficulty sleeping and restlessness during sleeping due to pain, insufficient sleep quantity and
quality, anhedonia, decreased appetite and nausea when eating, sadness, worthlessness, and
hopelessness. Reported a variety of pain and somatic symptoms.
Diagnostic Impression
Depressive Disorder due to chronic pain with major depressive-like episode (F06.32)
R/O Posttraumatic Stress Disorder
R/O Bereavement Disorder
Genogram
Acupuncture ~ Auricular/Ear
Easy access, well tolerated
• Available in our office from MD, covered by Medicaid
• Patient stays dressed
• May do in group setting
Defined trainings/workshops
• Health professionals may learn skills to deliver in office, hospital, ERs, field work
• “NADA” protocol used in addiction programs
Somatotopic Map
• Ear reflects Whole Body
Whole Body Mapped onto Ear
~ points on ear correspond to areas on body ~
Clinical Progress
No improvements in patient’s pain symptoms.
• Pain worsened by: some foods (i.e., sticky rice, pumpkin); feeling
cold, drinking cold beverages
• Discontinued acupuncture after five sessions.
Minimal gains in coping with depression symptoms.
• First glimmer of acceptance – “the doctors can’t help”, no cure.
Ongoing
◦ Recent work-up through Rheumatology.
◦ Recent CPAP titration for recent OSA diagnosis.
◦ Behavioral health treatment and support.
Cultural Factors of Illness
Perinatal exposure to rainwater and lack of culturally
prescribed postnatal care as primary cause of illness.
• “It is said that in the villages where there is “nothing to help your
body return to normal,” women sometimes “get sick forever”.
(Neiman, 2007) But the women who stay indoors for a month don't
get sick. During this time, they never touch cold water, and they
drink and take a shower with hot or warm water. This tradition has
changed some for the Karen community in the U.S.” (Neiman, Soh,
Sutan, 2008).
Next steps
Benefit of Cultural Case Formulation
IF YOU:
• Facilitate a shared understanding with the patient of
symptoms, illness, and recovery.
• Identify and address cultural, linguistic, and social barriers to
treatment.
• Avoid cultural and ethnic stereotypes.
YOU WILL:
• Increase likelihood of accurate and meaningful diagnoses.
• Improve chances of treatment adherence and positive health
outcomes.
Session Evaluation
Please complete and return the evaluation form
before leaving this session.
Thank you!