While the need to address disparities in care is well known, few strategies for reducing disparities have been studied systematically.
Maine is the "whitest" state in the nation. Yet about 30 percent of students in Portland public schools are refugees or immigrants, or the children of refugees or immigrants. More than 90 percent of refugees from Africa (Congo, Rwanda, Somalia, and Sudan) and Iraq who have resettled in Maine live in Portland. Many Spanish-speaking immigrants have also settled in Portland, including those from El Salvador and Guatemala. Immigrants from Vietnam and Cambodia also live in the city.
The Coming-to-America Experience. "The coming-to-America experience, and the emotional and mental challenges that come with that move, are the same no matter where the families came from, and whether they came due to civil war or for dire economic reasons," said Grace A. Valenzuela, director of Portland Public Schools' Multilingual and Multicultural Center, and director of Caring Across Communities: Addressing Mental Health Needs of Diverse Children and Youth in Portland. The Robert Wood Johnson Foundation national program brought school-connected mental health services and, in most cases, supportive services such as case management to immigrants and refugees in Portland and at 14 other sites in eight states from 2007 until 2010. Portland Public Schools was the lead agency for the project, which covered 18 schools from elementary to high school.
The emotional and mental health challenges of immigrants and refugees include anxiety, depression, family conflict, post-traumatic stress disorder, and the stress of learning to live in a new culture. But stigma against mental health services, the cost of those services, and a lack of awareness of their availability stopped families from getting the help their children needed.
What's more, social workers, therapists, and case managers did not understand the experiences of these families before they came to the United States, and the stresses they faced since arriving. Caring Across Communities in Portland focused on providing professional development for all these staff, as well as helping parents understand their new culture and showing how mental health services could help their children do well in school.
Building the Cultural Competence of Mental Health Providers. To learn about the needs of these families, the Portland Caring Across Communities project held 12 focus groups with refugees and immigrants from different countries—including middle school and high school students—and mental health providers. Project staff used the results to develop trainings in cultural competency for school-based social workers and local mental health providers. The project's Multilingual and Multicultural Center offered about 30 workshops on topics ranging from resettlement challenges and immigration law to working with interpreters. Along with sharing knowledge, these sessions led to better communication between once-isolated agencies.
Project staff also held sessions where traditional healers from different refugee and immigrant communities spoke to mental health providers about traditional healing practices, and what health and wellness means to people in their communities.
Providers Reach Out. Out of one of these sessions came the understanding that if the services were presented as helping children and families succeed—rather than as "mental health services" for help with "attachment disorder"—they had a better chance of being accepted. Language was important. Project staff also helped develop questions for mental health providers to ask immigrant and refugee families after a provider survey revealed that they did not know how to talk to these families.
Said one mental health professional who participated in the training: "The refugee experience, I had no idea. It sounds like hell on earth. It makes my heart hurt." Another said that understanding students' backgrounds would "help me become more supportive of special customs as well as learning."
The Caring Across Communities project "opened up Portland Public Schools' staff and our partners to not seeing our immigrant and refugee families as burdens, or groups of people needing help," said Valenzuela. These staff members now see people who have "a lot of strength and capacity, because they have already experienced things most people have not, and came out of it with resiliency."
Greater understanding of immigrant and refugee families also encouraged providers who may have been afraid of doing or saying the wrong thing to reach out to these students. Although the project was unable to collect clinical data on the mental health services provided and their impact on students, anecdotal evidence showed that many mental health providers expanded the number of refugee and immigrant children with whom they worked. One provider, for example, went from not working with any refugee and immigrant children to working with 39.
Working with Cultural Brokers. Along with listening to immigrant and refugee families and learning about their beliefs and needs, project staff also made good use of "cultural brokers" (bilingual and bicultural staff who know the local refugee or immigrant community) from the Multilingual and Multicultural Center and partner agencies, such as the center's Parent/Community Outreach Specialists. "Having cultural brokers who are trusted in the community is the way to get people to start talking," said Valenzuela.
The Multilingual and Multicultural Center chose partner agencies, such as the Community Counseling Center and Spurwink, a nonprofit organization providing behavioral health, educational, and residential services, which could provide case managers from different cultures. Other key partners included the Center for Grieving Children—which developed a weekly after-school group program for children who had suffered trauma—several city departments, including student health centers; and the University of Southern Maine.
Connecting with Parents and Students. To reach immigrant and refugee parents, who did not participate in traditional parent-teacher organizations, project staff started a Parent Information Network. The network held monthly meetings during the school year on schools, law, health, safety, and other topics of interest to immigrant and refugee parents. Bilingual staff from Parent/Community Outreach Specialists facilitated these meetings.
In schools, students participated in programs designed to prevent mental health problems led by a school social worker and a cultural broker from the community. These programs included identity development support groups for Cambodian girls, Latino boys, Somali boys, African girls, and a multicultural group. When students needed mental health counseling or other help, the school social worker referred them to someone from the Community Counseling Center or Spurwink.
Sustaining the Work. Under a three-year THRIVE grant from the U.S. Department of Education's Office of Safe and Drug-Free Schools, awarded in 2010, staff members at Portland Public Schools are extending the work begun during Caring Across Communities. The grant funds mental health prevention efforts and counseling services for all students at one elementary school and one middle school in Portland. The prevention efforts help students who are new to the United States or the school district adjust and develop socially and emotionally. A community partner provides the counseling services.
Portland Public Schools continues to offer training in cultural competency for school-based social workers and local mental health providers, as well as other training. The public school system in Androscoggin County, near Portland, has adopted the training series.
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