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The chapter on acculturation describes the possible reactions of the immigrant to the encounter with the new host culture and describes the history and meaning of the term acculturation, the strategies used by immigrants in order to adapt... more
The chapter on acculturation describes the possible reactions of the immigrant to the encounter with the new host culture and describes the history and meaning of the term acculturation, the strategies used by immigrants in order to adapt to the new host culture, the styles and models of acculturation, and the distance or proximity in which they place themselves with respect to the new culture that surrounds them. It explains the concepts of acculturation stress—the risk factors and protective factors and other variables that facilitate or slow down acculturation—and the concept of acculturative family distancing, which occurs when different members of the family acculturate at different rates and the conflicts that are generated by this phenomenon. The chapter also explains the role of the acquisition of a new language and how acculturation is measured, the epidemiological findings brought by acculturation on the different generations of the immigrant family, and how individual, family, and community factors influence acculturation. It also explains the role of acculturation in nonimmigrant historical minorities who have resided in the country but do not partake of the mainstream culture. Treatment interventions are discussed, and the chapter is further illustrated with case studies.
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The chapter on criminality among immigrants seeks to dispel the myths and to clarify the true statistics of criminality among the immigrant population in the United States. It provides a historical perspective of criminality and... more
The chapter on criminality among immigrants seeks to dispel the myths and to clarify the true statistics of criminality among the immigrant population in the United States. It provides a historical perspective of criminality and immigration and describes the anti-immigrant currents and rhetoric that have emerged throughout the history of the country. It describes the crime rates and socioeconomic factors that generate criminality among legal and undocumented immigrants, providing an in-depth analysis of the three principal federal, state, and local justice system U.S. government databases in order to clarify the true statistics on immigrant criminality. It discusses the variables that affect the levels of criminality, including immigration, class, and race and the statistics and factors affecting criminality among second-generation immigrants and beyond. It describes what constitutes a cultural crime and the plight of immigrants as victims, including border crossings, human trafficking, violence, and exploitation and the contribution of post-traumatic stress disorder as a cause of criminality and as a result of victimization. Ultimately, it discusses the dilemma of immigration as an issue of national security.
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The chapter on transnational identities, pilgrimages, and return migrations explains the concept and importance of the term transnationalism and the new socioeconomic dynamics that take place between immigrants to the United States and... more
The chapter on transnational identities, pilgrimages, and return migrations explains the concept and importance of the term transnationalism and the new socioeconomic dynamics that take place between immigrants to the United States and the flow of cultural exchange and monetary remittances to the relatives in the country of origin. It expands on how the use of new communication technologies and more accessible air transportation have contributed to globalization and how this globalization has changed the immigrant experience, leading to a process of interculturation. It expands on the particular immigrant experience of Puerto Ricans and also discusses the dynamics of those whose stay behind in the country of origin. This chapter explains the psychodynamic meaning of nostalgia and discusses the reasons and motivations that generate return migrations to the country of origin. It also discusses the socioeconomic and psychodynamic issues of those who chose to return and how the transfer of newly acquired skills and knowledge impacts the country of origin, as well as the psychodynamic and socioeconomic issues that result in the encounter between those who chose to stay and those who return. This chapter also discusses the meaning of pilgrimages to the lands, not of the immigrants’ birth, of their ancestral family histories and how these pilgrimages serve as intrapsychic organizers that lead to the integration and enrichment of the person’s cultural identity and may promote personal growth. The topics are explained and illustrated with various case studies.
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The concept of providing psychopharmacological treatment for children and youth remains controversial. This has especially been true regarding the use of monoamine oxidase inhibitors (MAOIs) due to their significant side effects and... more
The concept of providing psychopharmacological treatment for children and youth remains controversial. This has especially been true regarding the use of monoamine oxidase inhibitors (MAOIs) due to their significant side effects and concern about dietary adherence by children, youth, and their families. However, some literature and clinical experience exists on their use in common pediatric psychiatric disorders. This article reviews this literature and a case series in the context of these concerns and raises questions about the reconsideration of these agents in the pediatric population. [ Psychiatr Ann. 2014;44(11):507–512.]
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Research Interests: Poverty and Mental Health
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Background: Suicide is one of the leading causes of death across all age groups globally and poses a significant public health burden. In response to the United States Joint Commission National Patient Safety Goals, a tertiary hospital in... more
Background: Suicide is one of the leading causes of death across all age groups globally and poses a significant public health burden. In response to the United States Joint Commission National Patient Safety Goals, a tertiary hospital in the Northeast U.S. developed a suicide risk assessment and response protocol, consisting of systematic screening of patients for suicidal ideation/behavior with a screening version of the Columbia Suicide Severity Rating Scale (C-SSRS) and a response algorithm based on risk levels derived from the screen. Methods: A total of 837 nurses were trained and 24,168 patients ages 12 and above were screened with the C-SSRS Screener. Results: Posttraining interrater reliability on the C-SSRS Screener definitions of ideation and behavior was high and independent of level of education or mental health experience. Of the patients screened, only 144 patients (0.93%) were in the highest risk category, and they were assigned patient safety monitors until a follow-up consultation. The highest risk levels from the C-SSRS Screener reasonably identified subsequent attempts at self-injurious behavior during hospitalization. Screening resulted in lower burden due to reduction in the rate of psychiatric consultations and one-to-one observation shifts. Conclusions: These findings suggest that a systematic screening and clinical response protocol using the C-SSRS Screener can potentially enhance the ability to identify suicide risk in the general hospital population and focus services on patients with the most need.
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Research Interests: Psychology and Psychiatry
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Background and objectives: Trauma memories lay at the core in etiopathogenesis of post-traumatic stress disorder (PTSD). Using pharmacological and cognitive behavioral treatments that specifically target trauma memories can improve the... more
Background and objectives: Trauma memories lay at the core in etiopathogenesis of post-traumatic stress disorder (PTSD). Using pharmacological and cognitive behavioral treatments that specifically target trauma memories can improve the outcome. Ketamine has been shown to rapidly improve symptoms in PTSD and comorbid depression, but unfortunately these effects are short-lived. Trauma Interventions using Mindfulness Based Extinction and Reconsolidation (TIMBER) psychotherapy is a type of mindfulness based cognitive behavioral therapy that targets the trauma memories. TIMBER psychotherapy in combination with (R,S)-ketamine are increasingly used to treat PTSD and comorbid depression. This study aims to determine if the combination of (R,S)-ketamine chemotherapy and TIMBER psychotherapy would produce a positive synergistic response in patients with PTSD. Design: This is a randomized, placebo-controlled, cross-over clinical study. Methods: Because response to ketamine alone is short-lived, this study combined TIMBER with a single infusion of 0.5 mg/kg (R,S)-ketamine to sustain its therapeutic effects. Ten patients with chronic and refractory PTSD were randomly assigned to two groups (n = 5 each): TIMBER-K group patients received ketamine infusion in combination with 12 TIMBER sessions (3 sessions in the first week followed by 9 sessions conducted on a weekly basis) and TIMBER-P group patients received placebo (normal saline infusion) in combination with 12 TIMBER sessions. The patients in the TIMBER-P group were switched to those in the TIMBER-K group after they experienced a sustained relapse. Outcome measures: PTSD Checklist (PCL), Clinician Administered PTSD Scale for DSM-IV (CAPS), the 17-item Hamilton Rating Scale for Depression (Ham-D-17, clinician rated), Beck Anxiety Inventory (BAI), and Montreal Cognitive Assessment (MoCA) at baseline and 8 hours after infusion were used to investigate if ketamine selectively affected trauma memories leaving the general memory intact. The mindfulness interventions in TIMBER were personalized based on subject's scores on Assessment Scale for Mindfulness Interventions which was administered at baseline, and after 5 sessions and 9 sessions (completion) of TIMBER. In this study, scores on CAPS and PCL scales were the primary outcome measures. Results: In the acute phase trial ( first 3 months after infusion), nine out of 10 subjects showed robust response in primary outcome measures (PCL and CAPS scores for PTSD) and in the secondary outcome measures (Ham-D-17 and Beck Anxiety Inventory for depression and anxiety respectively) with a sustained response of 31.78 ± 18.29 days. The TIMBER-K group had a more sustained response (33 ± 22.98 days) compared to the TIMBER-P group (25 ± 16.8 days, P = 0.545). After switch from TIMBER-P group to TIMBER-K, patients experienced significantly prolonged response (49 vs. 25 days, P = 0.028). There were no intolerable side effects or dropouts during the 18-month follow-up period. Conclusion: TIMBER psychotherapy augmented with low dose (R,S)-ketamine prolongs the therapeutic effects of the later and may be a valuable treatment option for PTSD. Trial registration: ClinicalTrials.gov identifier: NCT02766192
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Suicide in the United States has surged to the highest levels in nearly 30 years, with increases in every age group, particularly among women and with the exception of older adults. Approximately 1 in 25 teenagers in the United States has... more
Suicide in the United States has surged to the highest levels in nearly 30 years, with increases in every age group, particularly among women and with the exception of older adults. Approximately 1 in 25 teenagers in the United States has attempted suicide, and as many as 1 in 8 has thought about committing suicide. This problem is especially concerning among Latino adolescent girls, who have the highest suicide rates among all adolescent groups nationwide. The statistics reveal that in the United States, 15.6% of Latino adolescent girls have attempted suicide one or more times and up until recently, this problem had received scant attention in the media and in the medical field Nock et al. (JAMA Psychiatry 70(3):300–10, 2013). This chapter will review the recent epidemiological findings on Latino youth suicide, will examine the possible etiologies underlying this problem, and will discuss the currently available evidence-based treatments.
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The growing number of culturally diverse youth in the USA implies a social and professional responsibility to provide culturally informed mental healthcare to address their common and diverse needs. Suicidality in diverse youth requires a... more
The growing number of culturally diverse youth in the USA implies a social and professional responsibility to provide culturally informed mental healthcare to address their common and diverse needs. Suicidality in diverse youth requires a culturally informed clinical approach both in the immediate aftermath of a suicidal crisis and also in the treatment of underlying psychopathology, precipitating conflict, or perpetuating dynamics. This chapter outlines principles for culturally informed treatment associated with suicidality and useful tools and guides that can assist in such treatment.
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Culture has been defined as an integrated pattern of human behaviors including thoughts, communication, actions, customs, beliefs, values, and institutions of a racial, ethnic, religious, or social nature (Pumariega et al. 2013). Hughes... more
Culture has been defined as an integrated pattern of human behaviors including thoughts, communication, actions, customs, beliefs, values, and institutions of a racial, ethnic, religious, or social nature (Pumariega et al. 2013). Hughes (1993) further defined culture as a socially transmitted system of ideas that (1) shapes behavior, (2) categorizes perceptions, (3) names selected aspects of experience, (4) is widely shared by members of a particular society or social group, (5) is an orientating framework to coordinate and sanction behavior, and (6) conveys values across the generations. Most societies define normality and deviance in human behavior within the context of culture, including the acceptable range of affective expressiveness, idioms and threshold of distress, and expressed beliefs and actions.
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This chapter discusses psychopharmacological treatment for children's emotional and psychiatric disorders. It considers approaches to the selection of pharmacological agents. It then reviews the current state of... more
This chapter discusses psychopharmacological treatment for children's emotional and psychiatric disorders. It considers approaches to the selection of pharmacological agents. It then reviews the current state of psychopharmacological treatment with children and adolescents, focusing on pharmacological agents for the treatment of established psychiatric diagnoses and psychopharmacological agents selected to control or treat behaviors experienced by the child regardless of the presence of a clear diagnosis.
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The chapter on the psychodynamic aspects of migration explains the parallels between the process of migration and of life and human development, which can be understood as a series of attachments and separations that can lead to personal... more
The chapter on the psychodynamic aspects of migration explains the parallels between the process of migration and of life and human development, which can be understood as a series of attachments and separations that can lead to personal growth but involve mourning for what is lost and forming new attachments. It explains the concept of culture shock and the process of transformation of the identity of the immigrant, the dynamics involved in acquiring a new language, and the psychodynamic challenges of starting a life in the new host country. It explains the psychological defenses that the immigrant may put in place to deal with the massive losses of migration and adapt to the new country, such as the loss of past human connections and material possessions, as well as the loss of a familiar climate and geography. It discusses the family dynamics of leaving children behind in the care of relatives and later reunifications with the immigrant parents in the new host country. The chapter offers treatment recommendations to deal with these issues. The chapter is also illustrated with case studies.
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The chapter on treatment interventions for immigrants, refugees, and their families describes the importance for clinicians to familiarize themselves with how to treat these populations given the changing demographics in the United... more
The chapter on treatment interventions for immigrants, refugees, and their families describes the importance for clinicians to familiarize themselves with how to treat these populations given the changing demographics in the United States. It explains the cultural competence model, the cultural sensibility model, and the community systems of care model, as well as other variations of treatment that take into account cultural nuances. The chapter outlines specific recommendations to treat child, adolescent, and adult immigrants and refugees based on the Practice Parameter on Child and Adolescent Psychiatric Culturally Competent Care by the American Academy of Child and Adolescent Psychiatry and other sources. These include how to overcome barriers to mental health treatment, the role of language barriers and how to overcome them, the generational challenges in treating the family, awareness of cultural biases and how to address them, understanding cultural idioms of distress in diagnosis and formulation, the need to assess and treat immigration-related losses and traumas and to evaluate acculturation-related family conflicts, identification of key family members in the treatment, and the need to design treatment interventions that are consonant with the cultural values and beliefs of the immigrant family. The need to provide evidence-based pharmacological treatments and to consider ethnopharmacological factors is addressed. Other evidence-based treatments such as cognitive behavioral therapy for post-traumatic stress disorder, testimonial psychotherapy, narrative exposure therapy, eye movement desensitization and reprocessing, and others are discussed.
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Immigration, Cultural Identity, and Mental Health is a unique book because it explains culture and identity from a developmental perspective, exploring the psychological, social, and biological aspects of the immigrant and refugee... more
Immigration, Cultural Identity, and Mental Health is a unique book because it explains culture and identity from a developmental perspective, exploring the psychological, social, and biological aspects of the immigrant and refugee experience in the United States and how they help to shape the person’s cultural identity. It also covers the sociological, anthropological, political, and economic aspects of the immigrant experience and how these variables impact mental health, thus presenting the experience of migration and acculturation from a very broad and humanistic perspective, illustrated with multiple real-life case examples. The book explains how a broader access to travel and new communication technologies are responsible for the rapid global dissemination of cultural norms, values, and beliefs across national borders, facilitating a process of inter-culturation, in which both the new arrivals and members of the host culture are influenced and transformed by their interactions with one another and how American children, adolescents and young adults are at the forefront of such new multicultural identity formation. It describes the emergence of transnational identities, the meaning of pilgrimages, the experiences of return migrations and the importance of the American narrative, which is at its core, an immigrant narrative. This is a book about the American identity and how immigrants have been absorbed into American society and how they continue to enlarge and transform America and the cultural identities of its inhabitants.
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The chapter on culture and identity defines the current use of these terms and discusses how culture influences identity formation from a developmental perspective, starting in early childhood and throughout the life span. It also... more
The chapter on culture and identity defines the current use of these terms and discusses how culture influences identity formation from a developmental perspective, starting in early childhood and throughout the life span. It also introduces new neurobiological findings related to theory of mind, neural mapping, object representation, and emotional reactivity and how these exert an influence on culture and identity formation. It covers a historical perspective that includes the contributions of pioneers such as Freud, Vigotsky, Montessori, Bandura, Mead, and Erikson. It also discusses ethnicity and race and the social and biological origins of prejudice and explains the meaning of ethnic-racial socialization messages, the dynamics of biracial identities, the importance of language in the development of the American identity and the role of culture and identity in psycho-social functioning and resiliency, including such variables as religion and spirituality. It also describes the influences of globalization and the diminishing importance of national boundaries on cultural identity for both minority and majority group members. Some of the concepts are illustrated and explained with clinical cases.
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The chapter on immigration trends describes the current legal and illegal paths of immigration to the United States; a historical perspective of the reasons for migration; the past and current numbers of immigrants who have arrived in the... more
The chapter on immigration trends describes the current legal and illegal paths of immigration to the United States; a historical perspective of the reasons for migration; the past and current numbers of immigrants who have arrived in the United States and their demographic profile; which countries contribute immigrants and which states receive them; the changing race and ethnicity of the immigrants throughout the country’s history; the immigrants’ levels of education, skill sets, and financial attainment at the time of arrival and after the second generation. A demographic profile of the illegal immigrants, their vulnerability for exploitation, and their financial importance to the country’s economy is presented. The composition of immigrant families, some of the psychological effects of geographical separations and deportations on the family, factors that facilitate or impede assimilation and adaptation, the intergroup relations, values, and political orientation of the different immigrant groups, and the immigrants’ financial contributions to the United States are discussed.