Cultural Competence and
African Americans with Mental
Illness
The President’s Commission on Mental Health
August 6, 2002
King Davis, Ph.D.
Robert Lee Sutherland Chair in Mental Health & Social Policy
School of Social Work, University of Texas at Austin
Co-Chair of the National Leadership Council on African American Behavioral Healthcare,
Inc.
Introduction
• I am here today representing the National
Leadership Council on African American
Behavioral Health. The Council is an
organization of African American
consumers, family members, providers,
professional associations, government staff,
ministers and university professors that was
formed close to one year ago. Each of the
mental health disciplines is represented.
Introduction (cont.)
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The Leadership Council is the first non-profit
organization of its kind in our community that
brings so many African American groups,
involved in behavioral health, to the same table
under a single umbrella. We work
collaboratively with similar organizations from
the Asian-Pacific Islander, Latino, and Native
American communities.
Our interest today and focus is cultural
competence as a tool for change.
Why is Cultural Competence
Important?
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Potential Cost Savings: people & dollars
a. Excess use of inpatient d. >Diagnostic error
b. High rates of recidivism e. >Insurance rates
c. Under-use of outpatient
f. LOS
Ethical Base of Professions
Quality of Care Demands it
Potential Improvement in Diagnosis
Potential Improvement in Treatment
Potential for Prevention
Potential for Increasing Participation in Policy
Dilemmas of Mono-Cultural Service
Design
Source: Davis, King (2001). In Veeder & Peebles-Wilkins, London: Oxford University Press.
What is Culture?
• Ways of behaving shared by human groups,
which taken as a whole, constitute their
culture. Each human society has its own
culture, distinct in its entirety from that of
any other society (Beals & Hoier, 1959)
• The learned patterns of behavior and
thought characteristic of a societal group
(Harris, 1985).
Basic Assumption
• Culture is an important variable in
determining how people
(consumers & providers) see and
interpret (know) the world around
them and the basis of how they
make decisions.
Defining Cultural Competence
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Clinical Based Definition
• Cultural competence is a set of behaviors,
attitudes, and policies that come together in
a system, agency, or among professionals
that enable them to work effectively in
cross-cultural situations.
Source: Cross et al. (1989).
Defining Cultural Competence (2)
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Need-Based Definition
Cultural competency is the acceptance and
attention to the dynamics of difference, the
ongoing development of cultural
knowledge, and the resources and flexibility
within service models to meet the needs of
minority populations.
Source: Cross et al. (1989).
Defining Cultural Competence (3)
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Market-Based Definition
• Cultural competence is the integration and
transformation of knowledge, information, and
data about individuals and groups of people into
specific clinical standards, skills, service
approaches, techniques, and marketing programs
that match the individual’s culture and increase the
quality and appropriateness of health care and
outcomes and lowers costs.
Source: Davis, King (1997).
Applying Cultural Competence
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Domains
1. Needs Assessment
2. Information Exchange
3. Service Design & Standards
4. Human Resource Development
5. Policies and Plans
6. Measurement of Outcomes
Historical/Current Disparities
1760 -2002
• >Diagnosis of Severe Illness
• Frequency of Re-Admissions
• Frequency of Involuntary
Admissions
• Utilization of Inpatient Services
• Death Rates in Hospitals
• Length of Stay
• Higher Dosages of Medication
• Knowledge/Information
• Stigma/Fear/Myth
• Use of Outpatient Services
• <Use of Standard Treatments
Workforce Composition
Epidemiological Study
Voluntary Participation
Involvement in Policy
Shortage of Outcome Studies
Research Involvement (directors)
Location of Services
Help Seeking & Utilization Patterns
Homelessness
Dual-diagnosis
Errors in Diagnosis
Family/Consumer Experiences in System
Theory & Training Foci: Immunity/Over-use
Sources: Neighbors et al (2002); Snowden et al (2001) and others (see bibliography).
Prospective Frequency Of Illness
Source: Davis, King., Johnson, Toni, & McClendon,A. (2002). Guidebook. Baltimore: Casey Foundation
Mental Health: A Report of the Surgeon General, DHHS, 1999.
Admissions per 100,000 by Race,
Ethnicity & Type of Facility
Involuntary Admissions by Race
Source: Ramm, D. (Fall, 1989). Overcommitted. Southern Exposure, 14-17.
Policy Actions Needed
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Priority on MH of Populations of Color
Cultural Competence Standards
Consumer/Family Participation
Shift to a Disability Model
Involvement in Research
CC in Federal Agency Policy
Family Education Programs
MH Services in Jails
Parity Legislation
Revisions of Execution Policies and MI
Continuing Education Requirements
Funded Demonstration Projects
Focused Distribution of Research Funds
Enhanced primary care
National Action Conference
Licensure Requirements
Participation on Panels
New Research Scales
Church Linkages
Alternative Theory
Consumer Education Programs
Priority on Prevention
Newsletters/Clearinghouse
MH Policy Study Centers
Stigma Reduction Studies
Revised University Curricula
Services for Children
Online Sources
Source: National Planning Meeting on African American Mental Health (in press); Report of
National Leadership Council on African American Behavioral Health (2002).
Who Uses Cultural Competence?
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Coca Cola/Pepsi Cola
Budweiser
General Motors
IBM
Time Warner
HMOs
Disney Europe
Department of Defense
NCQA
JCAHO
Managed Health Care
California DMH
Texas DMHRM
Virginia DMHMR
National Planning Report
Source: National Leadership Council on African American Behavioral Health (2002).
http://www.utexas.edu/ssw/faculty/davis/naamh.pdf
Development of Standards
Quick Guide to Implementation
Source: The Hogg Foundation for Mental Health, University of Texas at Austin
Future Research
• Conceptualization of cultural competence:
determination of working concepts;
• Outcomes from studies in which cultural
competence is applied and where it is not;
• Cost of applying cultural competence &
potential budgetary savings;
• Differences in outcomes from different
approaches to cultural competence.
Conclusions
• Medical and psychiatric assessments have a high
error rate when applied to minority populations;
• Cultural competence appears to approve
assessment quality and accuracy;
• Contributions of cultural competence require
additional research;
• Adoption of cultural competence will require
extensive continuing education and revisions in
professional education.