Lisa R. Fortuna, MD, MPH Norah Mulvaney-Day, PhD

Helena Hansen, MD & PhD candidate Margarita Alegria, PhD

Center for Multicultural Mental Health Research

Supported by NIMH Latino Research Program Project &An Excellence in Partnerships for Community Outreach, Research on Health

Disparities and Training (EXPORT) Center Grant

Returning Home: Community Reentry and Mental Health Services

Experiences among Latino Juvenile Offenders

Outline

• Introduction

• Motivation

• Study Objectives

• Methods

• Analyses

• Results & Narratives

• Implications for Mental Health Services

Introduction• Latino youth are three times more likely to be

incarcerated than whites (Youth Law Center, 1996 )

• Although more than half of detained Latinos received specialty mental health services, those with psychiatric disorders are significantly underserved compared with their white counterparts. (Hough et al, 2002)

• Latino adolescents with psychiatric disorders enter specialty mental health services at a later age and had made significantly fewer mental health service visits in the previous year. (Hough et al, 2002)

Motivation

• Detailed studies of the perspectives of young Latino ex-offenders on mental health issues and services has received less attention.

• We need to examine these issues in the context of community and reentry. – Services– Experiences– Opportunities

Study ObjectivesIdentify (qualitatively)

potential areas of service enhancement:

1) Mental health experiences of Latino young adult ex-offenders and attitudes towards mental health care

2) How these experiences may relate to entry and retention into mental health services for these young adults.

MethodsPurposive sample of Latino young adult ex offenders

age 18-24– Recruitment of 16 young adults ( target 15-20)– Heterogeneity ( gender, language and time in US, ethnicity)– Juvenile justice involvement and community reentry– Able to consent for self ( less barriers related to parental

involvement)– Examination for recurrent and overlapping themes

In-depth interviews– Interview 1-1.5 hours– Open ended question with probes– Audio taping with permission or notes

Analyses• Data were analyzed using a grounded theory approach

(Glazer & Strauss, 1996).

• Modifications made to interview guide during the course of data collection to deepen exploration of recurrent themes for analysis.

• A preliminary coding system was developed by the first author independently and then together with a second coder who blindly coded a subgroup of interviews.

• Thematic categories and an emergent, preliminary framework for understanding youth reentry were also reviewed with key informants for conceptual validity.

RESULTS

Treatment History

– Most (75%) of the participants had experienced some interaction with the mental health system

– Engagement in any mental health care for all of the participants was short term (3 or fewer visits).

– The services they want are not the ones they are getting

Attitudes and Experiences

1) Coercion

2) and

3) Clinical Stereotyping

1) Personal Agency

2) Authentic Image

3) Mutual Recognition

4) Belonging and Proactivity

vs.

Personal Agency vs. Stereotyping

Young people described feeling stereotyped when they first engage with clinicians

“They also assume all kinds of things about me.”

--Cidro--22 year old Honduran male

“The therapist just assumed that I had a bad family, that my mom was doing drugs, and that I was poor.”

--Joey--19 year old PR male

Clinical Stereotyping

“They got tired of me running away [from foster homes and residential housing] so they had to lock me down. All of the kids in there had to be on medication. People feel that medication is going to help your depression.”

—Emma, 18 year old Puerto Rican female

Coercion is at the forefront of initial experiences of what it means to be involved in mental health care services.

Coercion

“But, the day reporting center person—she made me go to the therapist because I get angry a lot…Just talk to me about what I want to do, what I need and then I feel fine”.

Pablito, 19 year old Salvadorian male

Personal Agency

“I feel the anger management program was good—they were not strict—they would sit down and listen to you…Then the staff could support you in what you have done well but you were the one that really did it.”

-- Emma, 18 year old Puerto Rican female

Authentic ImageYoung people want to feel that a practitioner or

clinician recognizes the experiences that are relevant to their lives.

“She never really asked about who I really am

and what I wish for myself.”

--19 year old Puerto Rican female

Mutual Recognition

‘I liked the Puerto Rican counselors…I felt they could understand where I was coming from and what I was about. This always felt like such a rare thing for me—even from my family.

--Dedra, 18 year old Puerto Rican female 

Belonging and ProactivityUnderlying these commentaries is a desire for therapeutic

processes where they feel supported, heard, recognized and gain more control over their own lives through:

–community contribution

–context

– support

Belonging and Proactivity

“I can’t help myself. My mind is already too messed up. I have tried the therapy, medications, but I know my healing is not going to happen that way. Maybe I can help others.”

--Ray, 20 year old African American /Latino male

Belonging and Proactivity

“Circle is just the bomb—people letting out those tears. There are hilarious parts and sad parts—everything you do out here in life…”

--Javier--22 year old PR male

Belonging and Proactivity

• “You learn and then you teach circle. There are hilarious parts and sad parts—everything you do out here in life. I have never seen people cry all together like that…

--Javier--22 year old PR male

Belonging and Proactivity

“I can talk to those in school. I can ask a kid, what are you doing? I can help them understand...In that way, I can become better”.

--Javier--22 year old PR male

Implications

Young people also long to have support from those who see their potential and abilities and care about what they can contribute.

Coercion can undermine trust between clients from this population and clinicians, an important component of the therapeutic relationship

Implications

• Relationship building can be essential to prevent the erosion of trust in the therapeutic relationship in situations where coercion determines the client’s participation

• Good clinical practice and sustained open and caring community based relationships can be essential components of innovative client-centered reentry processes

• Community process vs. Individual process

Implications

The young participants gave examples of interventions, like Talking Circles, which although not culturally specific to Latinos may build on an interdependent vs. individualistic orientation of Latino culture.

Our findings challenge us to examine clinical norms with our study population.

• Are appropriate clinical boundaries between provider and patient experienced as distant and alienating by individuals from certain Latino cultures or communities?

• Can individual clinicians provide culturally connected care within the mental health system structures that are currently in place?

• What policy and system reforms are necessary in order to make our clinical services truly accessible to multicultural populations with needs like our study participants?

Conclusions & RecommendationsFor Latino youth offenders in community

reentry we need to focus on:– Importance of empathetic and engaged

therapeutic alliance– Supportive Interpersonal Relationships– Addressing clinical stereotyping ( clinician

training)– Group, community and relational processes