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Building Capacity Within CommunityBased Organizations: New Directions for Mental Health Promotion for Latino Immigrant Families in Urban Poverty Dana Rusch, Stacy L. Frazier & Marc Atkins

Administration and Policy in Mental Health and Mental Health Services Research ISSN 0894-587X Volume 42 Number 1 Adm Policy Ment Health (2015) 42:1-5 DOI 10.1007/s10488-014-0549-1

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POINT OF VIEW

Building Capacity Within Community-Based Organizations: New Directions for Mental Health Promotion for Latino Immigrant Families in Urban Poverty Dana Rusch • Stacy L. Frazier • Marc Atkins

Published online: 10 April 2014 Ó Springer Science+Business Media New York 2014

By 2050, Latino school-aged youth are projected to outnumber their non-Latino white peers (Fry & Gonzales, 2008). One in every four youth below 18 has at least one foreign-born parent, with 37 % of 40 million foreign-born in the US of Latin American descent (Grieco et al., 2012). Despite the fact that immigrant mental health has been an urgent national priority for over a decade (Flores et al., 2002; Pumariega & Rothe, 2010), it appears clear that the community mental health system cannot address this alone (Bringewatt & Gershoff, 2010; Huang et al., 2005) and falls short of strengthening natural supports within communities (Alegrı´a et al., 2010). Barriers to medical care thwart specialty referrals (Flores et al., 2005; Beniflah et al., 2013), and a dearth of bilingual, culturally competent providers exacerbates slow dissemination of empirically supported treatments into community mental health settings (Stagman & Cooper, 2010). We propose that high rates of mental health need and low service utilization among Latino immigrant families (DeRose et al., 2007; Kataoka et al., 2002; RAND, 2001) call for service models within non-specialty settings that build upon natural resources toward reducing risk factors and improving outcomes.

D. Rusch (&)  M. Atkins Department of Psychiatry (MC 747), Institute for Juvenile Research, University of Illinois at Chicago, 1747 W. Roosevelt Rd, Chicago, IL 60608, USA e-mail: [email protected] S. L. Frazier Clinical Science Program in Child and Adolescent Psychology, Center for Children and Families, Florida International University, Miami, FL, USA

Mental Health Risk Factors for Immigrant Families Immigrant families are over-represented in communities of concentrated poverty (Van Hook et al., 2004); 19 % live in poverty compared to 15 % of native-born with highest rates among Latino immigrants (24 %; Grieco et al., 2012). Immigrant families’ heightened vulnerability reflects multiple stressors, including low wages and limited job growth (Capps & Fortuny, 2006), discrimination (Lauderdale et al., 2006), and undocumented status (Sullivan & Rehm, 2005). A total of 5.5 million children in the US have an undocumented parent, though 80 % of these children are US-born citizens. As of 2010, one-third of all children in immigrant families had at least one undocumented parent (comprising 8 % of the US youth population) and research highlights increased risk for negative social, academic and mental health outcomes (see Yoshikawa et al., 2013). Latino immigrant families often have limited experience with formal sectors of care and encounter significant barriers when navigating the mental health system, such as stigma for help-seeking (Nadeem et al., 2007), lack of health insurance (Ku & Matani, 2001; Acevedo-Garcia & Stone, 2008), and language barriers (Yu et al., 2006). Increasing anti-immigrant rhetoric raises fears about seeking services, reflected by under-utilization rates among US-born children with noncitizen parents despite eligibility for public insurance (Huang et al., 2006). Under-utilization rates are concerning given high comorbidity among urban ethnic minority youth (McLaughlin et al., 2007), as well high rates of internalizing problems among Latino youth (Polo & Lopez, 2009; Choi et al., 2006) and associated suicide risk (CDC, 2012). Youth in immigrant families face unique risks due to trauma (Jaycox et al., 2002), immigration-related family separations (Rusch & Reyes, 2013), migration and acculturative stress (Potochnick & Perreira, 2010; Smokowski et al., 2009), and

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the psychological aftermath of US Immigration and Customs Enforcement (ICE) raids and removal proceedings (Chaudry et al., 2010). Risks for mental health problems among immigrant youth increase when family conflict is high (e.g., Smokowski et al., 2007), emphasizing the importance of family-centered service models.

Non-Specialty Sector Community-Based Organizations (CBOs) CBOs play an important role in providing services to at-risk urban youth (McLaughlin, 2000), and immigrant youth, in particular, receive important mental health benefits from CBO programs (Roffman et al., 2003). CBOs are touted as providing culturally responsive services, while focusing on capacity-building and empowerment (Foster-Fishman et al., 2001; Hardina, 2006) and facilitating community involvement in problem identification and innovation (Poole et al., 2002). Many CBOs promote an overall mission to serve the unique context of urban immigrant communities (e.g., Cordero-Guzman et al., 2008) by providing a range of social services; for example, adult learning programs, youth afterschool programs, legal aid and immigration advocacy. Moreover, CBOs address specific community needs by developing partnerships with local schools (Adger & Locke, 2000; Hong, 2011; Osterling & Garza, 2004), health-related service learning programs (Cashman & Seifer, 2008; Seifer, 1998), and federally-funded coalitions (Butterfoss et al., 1993; Gittell & Wilder, 1999). Non-specialty CBOs are uniquely positioned to support families because they have a visible and credible presence in the community (i.e., staff share cultural values and speak the language). Families may be more comfortable enrolling in programs and seeking services within settings that are less stigmatizing. Program enrollment is not contingent on insurance status, proof of legal documentation, or language proficiency, thereby increasing access and encouraging more consistent utilization. We propose that weaving mental health promotion goals more systematically and explicitly into existing programs may benefit immigrant families (see Rusch, 2013 for exemplars including adult ESL and youth after-school programs). We focus here on the potential to activate the CBO paraprofessional workforce around family engagement and advocacy toward supporting a model of mental health promotion.

The Role of Paraprofessionals in Family Engagement and Advocacy Organizational efforts toward engaging families and providing family support services (Hoagwood et al., 2008,

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2010) improve service utilization and outcomes related to parent self-efficacy, empowerment, and retention in care (Hoagwood, 2005). Advocacy and empowerment play an integral role in delivery of mental health services for Latino immigrant adults (Alegrı´a et al., 2008) and children (Jensen & Hoagwood, 2008; Olin et al., 2010a). Based on existing family advocacy models within the specialty mental health sector (Olin et al., 2010a, b; Rodriguez et al., 2011), we propose a CBO-based model of mental health promotion that strengthens the role and capacity of paraprofessionals to support immigrant families. Paraprofessionals (i.e., health advisors, family advocates/liaisons) are key players in the engagement process, as exemplified by research partnerships with Latino communities focused on disease prevention (Ramos et al., 2006), public health promotion (Rhodes et al., 2007), health education (Kim et al., 2005), and family-school partnerships (Callejas et al., 2006). Following a Community-Based Participatory Research framework (Israel et al., 1998; Minkler, 2005), we are collaborating with CBO partners to develop family advocacy activities that (a) reflect community stakeholders’ perceptions of mental health promotion goals; (b) align closely with CBO program initiatives and objectives; (c) strengthen and extend the skills, knowledge, and resources of paraprofessional staff; and (d) directly target proximal risk factors among Latino immigrant families that are empirically associated with children’s mental health outcomes.

CBO Partnerships with Community Mental Health We propose that non-specialty sector CBOs have a unique opportunity to promote mental health via their access to Latino immigrant families and play a critical role in building partnerships with community mental health and schools to support positive youth outcomes. CBOs are distinct from the specialty mental health sector with regard to: (a) workforce training that may not require certifications, advanced training or health care qualifications; (b) organizational structure not affiliated with university or institutional governance; (c) funding sources and financial reimbursement based on not-for-profit model vs. fee-forservice or third party reimbursement; and (d) organizational mission informed by local context and a social justice perspective. These distinctions highlight that investing in CBO-based models capitalizes on natural supports within a community and, by extension, enhances the sustainability of mental health promotion efforts. Although CBOs are neither designed nor expected to become de facto mental health settings, we propose that attending to innovation in regard to workforce, setting, and role/function responds to recent recommendations for intervention

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adaptation (NIMH, 2010) and workforce development (SAMHSA, 2013) and aligns with opportunities for workforce expansion encouraged by the Affordable Care Act (Mechanic, 2012). The activities supported and delivered by paraprofessionals can be envisioned in several forms. By example, Family Advocates (FAs) may provide both informational and instrumental support to facilitate positive and reciprocal linkages with teachers and schools on behalf of children. Consultation with ESL instructors may include ‘‘real-world’’ practice opportunities for parents to communicate with their child’s teacher, and consultation with parents may focus on creating home environments that support learning (e.g., practical strategies to support homework). Regarding community support, FAs may link immigrant families to additional resources by providing information about public assistance programs and children’s eligibility for public aid and services (Crosnoe et al., 2012). FAs may serve as liaisons, or ‘‘professional extenders’’ (Rogers, 1983), by linking immigrant families with community mental health services when their needs warrant more intensive support or treatment. They may help to address tangible barriers (e.g., transportation) or bridge a cultural gap that historically has marginalized immigrant families from neighborhood clinics. We also envision FAs as key players informing practice and policy stakeholders on the mental health needs of immigrant families.

Concluding Remarks Persistent disparities in mental health services utilization provide a compelling rationale for leveraging the potential of CBOs to promote mental health for immigrant families. CBO priorities align well with mental health goals, and existing programs present unique opportunities to develop family advocacy activities. How to strengthen organizational capacity without compromising their core mission or over-extending paraprofessional staff will be an important new direction for research, policy, and practice.

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