http://ebooks.abcclio.com/reader.aspx?isbn=9781610690140&id=A36
94C-2023
Mental Health Care Issues in America: An Encyclopedia
Author: Michael Shally-Jensen, Editor
Publication Date: 01/07/2013
Publisher: ABC-CLIO
Pages: 894
ISBN-10: 1610690141
ISBN-13: 9781610690140
Description:
Serious mental illness affects over 14 million people in the
United States, with 1 out of 4 Americans experiencing mild to
severe symptoms at some point in their lives. While advances
have been made in terms of the drugs available for treatment,
a more holistic approach may provide deeper insight into the
causes and effects of this pandemic.
Culturally Competent Mental Health Care
Sandra DiVitale
Poonam Ghiya
David Jordan
Mary Montaldo
Stanley Sue
Cultural competence is one of the most frequently discussed topics in the mental
health field. There is growing realization that a qualified therapist or counselor
must be culturally competent in order to work with diverse populations. Because of
the multiethnic nature of American society and the frequent interactions with other
cultural groups and societies throughout the world, skills must be developed to
effectively work with people from different cultures. Indeed, local and national
organizations have attempted to develop guidelines and standards for the provision
of mental health services to ethnic minority populations.
History of Efforts toward Cultural Competence
Certain developments in psychology have provided the foundation for cultural
competency. In the 1970s, the Association for Non-White Concerns (ANWC) in
Personnel and Guidance, a division of the American Personnel and Guidance
Association (APGA), met extensively to address the issue of ethnic mental health
disparities. A significant part of the organization’s mission was to recognize the
human diversity and multicultural nature of U.S. society. The ANWC strove to
enhance the development, human rights, and the psychological health of all
people as critical to the social, educational, political, professional, and personal
reform in the United States (McFadden & Lipscomb 1985). The organization
strived to identify and worked to eliminate conditions that create barriers to the
provision of effective mental health treatment.
Subsequently, the Association for Multicultural Counseling and Development
(AMCD) was established. As a division of the American Counseling Association,
the AMCD brought further support for the development of multicultural
treatment, including decreasing mental health disparities among diverse
populations. A major goal of the AMCD was to design programs that could
specifically improve ethnic and racial empathy and understanding in counselors
and therapists as well as enhance the understanding of cultural diversity (M. L.
Smith & Roysircar 2010).
Development of Organizational Guidelines and Practices
The American Psychological Association (APA) and its divisions have played a
large role in recognizing ethnic and cultural considerations in professional
practice. APA Division 17 (Counseling Psychology) and the National Institute for
Multicultural Competence (NIMC) strongly advocated for cultural competency.
The goal of this advocacy was twofold. These organizations advocated for
transformative changes in the mental health and human service sectors.
Furthermore, they promoted the principles and spirit of multiculturalism among
mental health professionals and other human service providers. An attempt was
made to have providers acquire the knowledge, skills, and awareness to work
respectfully, effectively, and ethically among persons from diverse groups and
backgrounds (D. W. Sue & Torino 2005).
APA Division 12 (Society of Clinical Psychology) established the section on the
Clinical Psychology of Ethnic Minorities. This section’s mission was to promote
research on clinical interventions with American racial and ethnic minority
populations. Furthermore, Division 12 fostered sensitivity training of all
psychologists as to cultural, racial, and ethnic issues.
One of the most significant events was the adoption by APA of the
2003 Guidelines on Multicultural Education, Training, Research, Practice, and
Organizational Change for Psychologists. The guidelines provided psychologists
with the rationale for the importance of, and need for, devoting efforts toward
multiculturalism and diversity. Importantly, they also gave principles and
procedures to follow in education, training, research, practice, and organizational
change (American Psychological Association 2003). Soon after, other
professional mental health organizations also established policies to enhance
cultural competency. In 2004, the American Psychiatric Association’s Steering
Committee to Reduce Disparities in Access to Psychiatric Care created a plan to
further cultural sensitivity and awareness and to diminish mental health
disparities. Finally, the National Association of Social Workers developed
standards and guidelines for social work practice designed to allow social workers
to effectively serve multicultural populations (National Association of Social
Workers 2007).
Definitions of Cultural Competency
Various definitions of cultural competency exist. Culturally competent
care has been defined as a system or intervention that values and
incorporates culture, considers assessment of the cross-cultural
relations, and adapts interventions to meet culturally unique needs of
clients (S. Sue et al. 2009). Chin views cultural competence as a set of
behaviors, attitudes, and policies that allow a system, agency, or
group of professionals to work effectively in cross-cultural situations
(Chin 2000). A precise definition of cultural competency or adaptation
was offered by T. B. Smith, Rodriguez, and Bernal (2011): the
systematic modification of an evidence-based treatment (EBT) or
intervention protocol to consider language, culture, and context so
that it is compatible with the client’s cultural patterns, meaning, and
values. All of the definitions stress effective interventions that
consider, or are compatible with, the culture, attitudes, values,
behaviors, and social contexts of clients.
In examining cultural competence, it is important to distinguish
between different levels in the provision of services. The first level is
the provider or therapist level. The provider works one-on-one with
clients usually in a treatment or case management role. Cultural
competency at this level involves culturally appropriate interpersonal
sensitivity, assessment, rapport building, therapeutic alliance, and
credibility. This first level—i.e., cultural competency among
therapists—has gained the most attention and research. The second
level occurs within an organization or agency. Examination is made of
the extent to which a mental health agency’s organizational structure
mental health programs are culturally responsive. These programs
include the organizational hierarchy, hiring of staff, establishment of
programs, program evaluation, outreach to communities, access and
availability of service, utilization, costs and benefits, and quality of
care for members of different cultural groups. The third level deals
with systems of care within a community. The organization and
structure of mental health services for different ethnic populations
(e.g., health maintenance organizations, geographic areas served, and
collaboration with community agencies, churches, schools, and law
enforcement agencies) are of interest at this level.
Justification for the Focus on Culturally Responsive Care
The impetus for cultural competency came from the growing cultural
and ethnic diversity of the United States and from the realization that
disparities existed in the accessibility, availability, and quality of care
given to members of ethnic minority groups. These disparities resulted
in underutilization of services as well as poorer treatment outcomes.
For example, compared to white Americans, ethnic minority groups
were often found to underutilize services or prematurely terminate
treatment. The National Survey on Drug Use and Health (Substance
Abuse and Mental Health Services Administration 2010) revealed that
African Americans, Hispanics, and Asian Americans were far less likely
than non-Hispanic white Americans to use mental health services,
even after controlling for prevalence of mental disorders.
The problems faced by ethnic minority populations have been
recognized for decades. The President’s Commission on Mental Health
pointed to a number of difficulties encountered by ethnic minorities in
the service delivery system (President’s Commission on Mental Health
1978). It noted that racial and ethnic minorities are underserved and
inappropriately served. More recently, the U.S. Surgeon General
(2001) and the President’s New Freedom Commission on Mental
Health (2003) concluded that these problems persist in the provision
of services to ethnic minority groups.
Given the disparities, important issues concerning equal justice or
ethical grounds have also been raised. Ethnic or racial disparities in the
quality of care violate notions of equity and fairness in the delivery of
services. For instance, the American Psychological Association (2003)
recommended that psychologists recognize that fairness and justice
entitle all persons to access to and benefit from the contributions of
psychology and to equal quality in the processes, procedures, and
services being conducted by psychologists. Why do the disparities
exist? Addressing this question is important because insights can be
gained into the causes of disparities and into the means for reducing
services inequities.
The sources of treatment disparities are complex, are based on historic
and contemporary inequities, and involve many players at several
different levels, including health systems, their administrative and
bureaucratic
processes,
utilization
managers,
health
care
professionals, and patients (Smedly et al. 2003). The delivery of
quality services to different populations is especially difficult because
of cultural and institutional influences that determine the nature of
services. Services often reflect the racism and biases found in the
broader society. Moreover, the cultures of various minority groups
have received little attention compared to that of the mainstream
culture. While culture is only one relevant factor in providing effective
mental health treatment, it is a critical one.
Culturally Competent Interventions
Considerable efforts have been expended in trying to develop specific
interventions that are culturally responsive. As suggested by S. Sue,
Zane, Nagayama Hall, and Berger (2009), components of treatments
can be categorized on the basis of method of delivery, content, and
specialized interventions (such as cognitive behavioral treatments,
storytelling interventions, and family therapies). They believe that
delivery can help to make an intervention more culturally consistent,
enhance the credibility of the treatment or provider, or render the
treatment understandable to ethnic minority clients. Common types of
delivery include the use of bilingual therapists who can speak the
ethnic language of clients (e.g., translating materials or having
bilingual therapists), matching the ethnicity of therapists with clients,
changing the interpersonal style of the intervention (e.g.,
showing respeto or culturally appropriate respect with Hispanics), or
providing a cultural context for interventions. These modifications
share a common feature in that they involve generic applications that
can be implemented across most types of treatment (e.g.,
psychodynamic, behavioral, and cognitive-behavioral).
Culturally adapted content refers to introduction of issues in therapy
that deal with cultural patterns, immigration, minority status, racism,
and background experiences. The content may serve to increase
understandability and credibility of the intervention and to
demonstrate the pertinence of the intervention to the real-life
experiences of clients. Finally, specialized interventions involve the
discovery or specific treatments or modification of therapies that are
more culturally compatible with clients or the incorporation of cultural
rituals or practices in treatment.
Studies have supported the value of some of these strategies. When
mental health services were designed specifically for the local context
and provided in their own ethnic neighborhoods, Asian American
clients living in Los Angeles were found to have better outcomes than
their counterparts attending mainstream clinics (Yeh, Takeuchi, & Sue
1994). Using culturally relevant support services like community
members, spiritual leaders, and extended family, better mental health
outcomes have also been demonstrated. For instance, Latino children
showed significant reductions in presenting symptoms after one year
when their mothers were included in their treatment recounting
cultural folk stories (Costantino, Malgady, & Rogler 1986).
Furthermore, historically disenfranchised groups tended to seek out
and use mental health services when their cultural values match those
addressed in the interventions provided. For example, African
American clients tended to remain in treatment when mental health
treatment included Afrocentric values (Banks et al. 1998; Oliver
1989). Likewise, using the ecological validity framework, Duarte-Velez,
Bernal, and Bonilla (2010) demonstrated how a culturally adapted
cognitive-behavioral therapy (CBT) could be flexibly adapted to
incorporate client
162
163
values, preferences and context while still retaining fidelity to its
treatment protocol when addressing the needs of a gay Latino
adolescent client. The authors cited a number of preexisting efficacy
studies for CBT with built-in cultural flexibility, which are sometimes
termed “living manuals.”
Outcomes of Specific Cultural Competency Strategies
Ethnic Match
The literature on matching therapists and clients based on ethnicity
has demonstrated mixed results. Some studies have found that when
clients are matched to therapists by native language and ethnicity,
they have tended to stay in treatment longer and to report satisfaction
with treatment (Campbell & Alexander 2002). Generally, when
therapist and client are ethnically matched, research shows that the
client is less likely to drop out of therapy, with the possible exception
of African American clients, and the clients attend more therapy
sessions (Maramba & Nagayama Hall 2002; S. Sue et al. 1991).
However, a recent meta-analysis of this research revealed that ethnic
match did not produce any positive effects on treatment outcomes
(Griner & Smith 2006). The reasons for the discrepancy between the
results seen for length of treatment and outcome measures due to
ethnic match are unclear. One hypothesis is that the ethnic match
produces an initial attractiveness feature for the client, which causes
him or her to stay in treatment longer but does not affect therapeutic
results in the long run. It is also possible that ethnic or language
match between clients and therapists is important in certain situations,
as when clients are unacculturated and/or recent immigrants (S. Sue
et al. 2009).
Language Match
Unlike the area of ethnic match, the research on matching therapists
and clients in terms of their language spoken is very clear. Research
demonstrates that matching clients with a therapists who speak their
primary language (if other than English) greatly improves treatment
outcomes (Meyer, Zane, & Cho 2008). In Griner and Smith’s (2006)
meta-analysis of 76 studies, treatment effectiveness was two times
greater in matched than unmatched language dyads involving
therapists and clients.
Overall Findings on the Effects of Culturally Based
Interventions
Overall, studies show that therapy that is culturally adapted in some
way is significantly more effective than treatments that are not
culturally adapted. This effect was especially true when clients were
older, Hispanic/Latino, or Asian American. Furthermore, the average
effect size of culturally adapted treatments for less acculturated
Hispanic/Latino(a) clients to be two times as large as the effect sizes
for moderately acculturated Hispanic/Latino(a) participants.
Interestingly, the more cultural adaptations used in the treatment
approaches, the better the outcomes for ethnic minority clients. The
research is not clear as to which cultural adaptations are the most
efficacious when several are used simultaneously.
Finally, a debate was introduced into the body of research about a
possible need to reconceptualize the thinking on culturally adapted
treatments (S. Sue 1988; S. Sue & Zane 1987). The suggestion was to
begin studying variables that were more proximal—that is, of more
immediate relevance—to therapeutic outcome than race or ethnicity.
Some of the more proximal variables suggested were: therapist
attitudes, values, knowledge, competency, etc. It was thought that
this could explain some of the more conflicting findings in the research
on the distal variables of race and ethnicity. Therefore some recent
studies have examined the effect of proximal variables on therapeutic
outcome.
A study by Meyer, Zane, and Cho (2011) found that college students’
perceptions of match when listening to an audio recording of a session
increased their perceptions of the therapist’s credibility. They also
found that the more attitudinally similar the participants perceived the
therapist to be to themselves, the more support they felt, and the
better the participants perceived their alliance to be with the therapist.
This therefore indicates that attitudinal match may be more important
than ethnic match in terms of therapeutic outcomes.
Other studies have examined cognitive matching in relation to its
effects on therapeutic outcome (Zane et al. 2005). Such studies have
found that therapist-client matching on perception of the goals of
therapy produced positive therapeutic outcomes. Additionally, T. B.
Smith, Domenech Rodriguez, and Bernal (2011) found that using
metaphors or symbols that were congruent with the client’s worldview
explained a significant portion of the variance in effect sizes. Finally,
clients who perceived similarity between themselves and their
therapists on the expectations about the benefit of treatment felt more
comfortable in later sessions and felt they got more out of sessions.
Conclusions
In terms of the clinical application of this research, there is an
overwhelming consensus among researchers and clinicians alike that
an urgent need exists for clinicians to integrate culturally adapted
treatments into their practices. As the research indicates, the more
cultural adaptations a clinician can integrate, the more effective his or
her work with culturally diverse clients will be. Moreover, the data
show a need for more therapists who speak languages other than
English in order to meet the needs of the many clients who do not
speak English as their primary language. However, the literature also
demonstrates the myriad ways in which therapists can match their
clients to make treatment more effective that go beyond their race or
ethnicity. Research suggests that cognitive match between
164
165
clinicians and their clients may also make treatment more effective,
and suggests that these more proximal variables may have a greater
impact on treatment. For the broader field of psychology, while there
is a clear recognition of the need for culturally competent care, the
research has not followed. More research is needed in order to clearly
define what approaches to being culturally sensitive work and how
established, empirically supported treatments can be adapted to work
with diverse populations. Only when this much needed research is
conducted can the findings be used to inform clinical practice and close
the gap in the services offered to minority groups.
See also African Americans and Mental Health;
See also American Indian and Alaskan Native Mental Health;
See also Asian American and Pacific Islander Mental Health Issues;
See also Diagnostic and Statistical Manual of Mental Disorders (DSM);
See also Latinos and Mental Health;
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