Transcript Slide 1

PROMOTING AND
SUPPORTING CULTURALLY
APPROPRIATE CHILDREN'S
MENTAL HEALTH SERVICES
Mario Hernandez, Ph.D.
Professor/Interim Chair
Department of Child and Family Studies
Louis de la Parte Florida Mental Health Studies
School of Mental Health Studies
The World Federation for Mental Health on Transcultural Mental Health:
Building a Global Response
Minneapolis, Minnesota - October 30, 2007
Purpose

Why is culture important to mental health?

To share the cultural competence continuum

To share a framework for building organizational
cultural competence

What is meant by the concept of “health
disparities?”
Assumption Underlying The Class

Culture and society play pivotal roles in mental
health, mental illness, and mental health
services

Understanding the wide-ranging roles of culture
and society enables the mental health field to
design and deliver services that are more
responsive to the needs of culturally and
linguistically diverse people
Why Culture Is Important


The dramatic change in our nation’s ethnic
composition is altering the way we think about
ourselves
The deeper significance of America’s becoming
a majority nonwhite society is what it means to
the national psyche, to individuals’ sense of
themselves and their nation – their (our) idea of
what it is to be American (Takaki, 1993)
What Is Culture?

Culture has been defined in various ways by
different disciplines and for numerous purposes
(Kao, Hsu, & Clark, 2004)

There will probably never be a single definition
of culture (Kao et al., 2004)
How Has Culture Been Defined?

The USDHHS Office of Minority Health (2000)
defined culture as:
“integrated patterns of human behavior that
include the language, thoughts,
communications, actions, customs, beliefs,
values and institutions of racial, ethnic,
religious or social groups” (p. 2).
How Has Culture Been Defined?

The United Nations Educational, Scientific and
Cultural Organization (UNESCO) defined culture
as:
"... culture should be regarded as the set of
distinctive spiritual, material, intellectual and
emotional features of society or a social
group, and that it encompasses, in addition to
art and literature, lifestyles, ways of living
together, value systems, traditions and
beliefs" (2002).
Maslow’s Hierarchy Of Needs:
Humanistic Theory
Self
Actualization
Esteem and Identity
Love and Belonging
Safety and Security
Physiologic (e.g., Food, Water)
(Cross, Bazron, Dennis, & Isaacs, 1989)
Assumption

Culture influences most, if not all, aspects of
human social interactions

Although culture is omnipresent, it is frequently
invisible, especially to those enmeshed within a
particular culture
Why Is It Important?

Striking disparities for culturally/linguistically
diverse people in mental health services despite
having similar community rates of mental
disorders

Less access to mental health care than do
whites

Less likely to receive needed care and when
they receive it, it is more likely to be poor in
quality

Sadly, relatively high levels of severity of a
mental health problem are required in order for
culturally-diverse individuals to overcome their
reluctance to seek help from a professional
Examples Of Disparities In Mental Health


African Americans
Less likely to seek treatment
When they do seek treatment, they are more
likely to use the emergency room for mental
health care, and they are more likely than whites
to receive inpatient care
For More Information please refer to SAMHSA Surgeon General's Report: Mental Health Fact Sheet for African Americans.
Available Online at: http://www.mentalhealth.samhsa.gov/cre/fact1.asp
Examples Of Disparities In Mental Health


Latinos/Hispanic Americans
In a national survey of high school students,
Hispanic adolescents reported more suicidal
ideation and attempts than whites and blacks
Studies also show that Latino youth experience
more anxiety-related and delinquency problem
behaviors, depression, and drug use than do
white youth
For More Information please refer to SAMHSA Surgeon General's Report: Mental Health Fact Sheet for Latinos/Hispanic Americans.
Available Online at: http://www.mentalhealth.samhsa.gov/cre/fact3.asp
Examples Of Disparities In Mental Health



Asian American/Pacific Islanders
Only 25 percent as likely as whites and 50
percent likely as African Americans and Latinos
to seek outpatient care
Less likely than whites to receive inpatient care
When they do seek care, they are more likely to
be misdiagnosed as "problem-free"
For More Information please refer to SAMHSA Surgeon General's Report: Mental Health Fact Sheet for Asian American/Pacific Islanders.
Available Online at: http://www.mentalhealth.samhsa.gov/cre/fact2.asp
Examples Of Disparities In Mental Health



American Indians/Alaska Natives
Appear to suffer disproportionately from
depression and substance abuse
Overly represented in in-patient care as
compared to whites, with the exception of private
psychiatric hospitals
The prevalence rate of suicide is 1.5 times the
national rate. Males ages 15 to 24 account for
2/3 of all AI/AN suicides
For More Information please refer to SAMHSA Surgeon General's Report: Mental Health Fact Sheet for American Indians/Alaska Natives.
Available Online at: http://www.mentalhealth.samhsa.gov/cre/fact4.asp
The Challenges We Face As A Field…

Income, Geographic Location, Language

Managed Care, Medicare/Medicaid

Stigma

Lack of trust

Insurance and related policies

System bias and institutional racism
Hernandez, M. Nesman, T., Isaacs, M., Callejas, L. M., & Mowery, D. (Eds.). (2006).
Examining the research base supporting culturally competent children’s mental health services. Tampa, FL: USF, Louis de la Parte
Florida Mental Health Institute, Research & Training Center for Children’s Mental Health.
Online at: http://rtckids.fmhi.usf.edu/rtcpubs/CulturalCompetence/services/CultCompServices.pdf
Cultural Competence
Definition Of Cultural Competence


“Cultural Competence” is a set of congruent
behaviors, attitudes, and policies that come
together in an agency that enables employees
to work effectively in cross-cultural situations
The word “cultural” is used because it implies
integrated patterns of human behavior that
include thoughts, communications, actions,
customs, beliefs, values, and institutions of a
racial, ethnic, religious, or social group
Hernandez, M. Nesman, T., Isaacs, M., Callejas, L. M., & Mowery, D. (Eds.). (2006).
Examining the research base supporting culturally competent children’s mental health services. Tampa, FL: USF, Louis de la Parte
Florida Mental Health Institute, Research & Training Center for Children’s Mental Health.
Online at: http://rtckids.fmhi.usf.edu/rtcpubs/CulturalCompetence/services/CultCompServices.pdf
Essential Elements Of Cultural
Competence: Dynamics Of Difference



When a system of one culture interacts with a
population from another, both may misjudge the
other’s actions based on learned expectations
It is important to remember that …creative
energy, caused by tension, is a natural part of
cross-cultural relations
The system of care must be constantly vigilant
over the dynamics of misinterpretation and
misjudgment
Cross, Bazron, Dennis, & Isaacs, (1989). Towards a culturally competent system of care: A
Monograph on Effective Services for Minority Children Who Are Severely Emotionally Disturbed:
Volume I Washington, DC: Georgetown University Child Development Center.
Definition Of Cultural Competence


The word “competence” is used because it
implies having the capacity to function
effectively
A Culturally Competent Agency acknowledges
and incorporates at all levels the importance of
culture, the assessment of cross-cultural
relations, vigilance towards the dynamics that
result from cultural differences, the expansion of
cultural knowledge, and the adaptation of
services to meet culturally unique needs
Summary Of Cultural
Competence Continuum

Cultural Destructiveness

Cultural Incapacity

Cultural Blindness

Cultural Pre-Competence

Cultural Competence

Advanced Cultural Competence
Cultural Competence Continuum

Cultural Destructiveness

Represented by attitudes, policies, and practices that
are destructive to cultures and the individuals within
the culture. For example: agencies, institutions that
promote cultural genocide: US Chinese Exclusion
Laws; KKK and other racial superiority groups.
Cultural Competence Continuum

Cultural Incapacity

Lacks the capacity or will to help minority clients and employees

System remains extremely biased, believes in the racial
superiority of the dominant group. Maintains paternal posture
toward “lesser races,” for example: lower expectations of
minorities and subtle messages that they are not valued.

Supports segregation as desirable policy

Enforces racial policies and maintains stereotypes

Disproportionately applies resources

Discriminates on basis of whether people of color “know their
place”
Cultural Competence Continuum

Cultural Blindness

Color or culture make no difference and that all people are the
same

Ignores cultural strengths

Encourages assimilation; thus, those who don’t are isolated

Blames victim for their problems

Views ethnic minorities as culturally deprived
Cultural Competence Continuum

Cultural Pre-Competence

“What can we do?” Desire to deliver quality services;
commitment to civil rights

Realizes its weaknesses and attempts to improve some aspect
of their services

Explores how to better serve minority communities

Agency may believe that their accomplishment of one goal or
activity fulfills their obligation to minority communities; may
engage in token hiring practices

Often only lacks information on possibilities and how to proceed
Cultural Competence Continuum

Cultural Competence

Acceptance and respect for difference

Expands cultural knowledge and resources

Continuous self-assessment

Pays attention to dynamics of difference to better meet client
needs

Variety of adaptations of service models

Seeks advice and consultation from the minority community

Commits to policies that enhance services to diverse clientele
Essential Elements Of Cultural
Competence
The culturally competent system of care is made up of
culturally competent institutions, agencies, and
professionals. Five essential elements contribute to a
system’s, institution’s, or agency’s ability to become more
culturally competent. The culturally competent system
would:

Value diversity;

Have the capacity for cultural self-assessment;

Be conscious of the dynamics inherent when cultures interact;

Institutionalize cultural knowledge; and

Develop adaptations to adversity
Cultural Competence Continuum

Cultural Competence – Advanced

Holds cultures in high esteem

Agency seeks to add to its knowledge base

Agency advocates continuously for cultural competence
throughout the system
Defining Organizational Cultural Competence
Background:
Defining Cultural Competence

Cultural competence has remained largely an
ideology with a set of guiding principles that lack
clear operationalization (Vega & Lopez, 2001)
Conceptual Model for Accessibility of Mental Health Services to
Culturally/Linguistically Diverse Populations
Definition: Within a framework of addressing mental health disparities within a community, the level of a human service organization’s/system’s
cultural competence can be described as the degree of compatibility and adaptability between the cultural/linguistic characteristics of a
community’s population AND the way the organization’s combined policies and structures/processes work together to impede and/or facilitate
access, availability and utilization of needed services/supports (Cross, Bazron, Dennis, & Isaacs, 1989; Siegel, 2004; CMHS, 1997).
Degree of compatibility defines level of
organizational/systemic cultural competence
Community Context
Cultural/Linguistic
characteristics of a
community’s population
Compatibility
Outcomes:
Reducing mental
health disparities
Organization’s/System’s
Infrastructure
Domain/
Functions
Direct Service
Domain/
Functions
Hernandez, M., & Nesman, T. (2006).
Characteristics Of The
Community Population
Cultural/Linguistic
characteristics of a
community’s
population
Compatibility
An organization’s/system’s
combined policies,
structures and
processes

Cultural View of Mental Health

History

Language Characteristics

Resource Characteristics

Strength Characteristics

Needs Characteristics
Conceptual Model for Accessibility of Mental Health Services to
Culturally/Linguistically Diverse Populations
Definition: Within a framework of addressing mental health disparities within a community, the level of a human service organization’s/system’s
cultural competence can be described as the degree of compatibility and adaptability between the cultural/linguistic characteristics of a
community’s population AND the way the organization’s combined policies and structures/processes work together to impede and/or facilitate
access, availability and utilization of needed services/supports (Cross, Bazron, Dennis, & Isaacs, 1989; Siegel, 2004; CMHS, 1997).
Degree of compatibility defines level of
organizational/systemic cultural competence
Community Context
Cultural/Linguistic
characteristics of a
community’s population
Compatibility
Outcomes:
Reducing mental
health disparities
Organization’s/System’s
Infrastructure
Domain/
Functions
Direct Service
Domain/
Functions
Hernandez, M., & Nesman, T. (2006).
Organizational/System Implementation Domains for Improving Cultural Competence
Infrastructure
Domain/Function
• Organizational Values
• Policies/Procedures/
Governance
• Planning/Monitoring/
Evaluation
Compatibility between the
• Communication
infrastructure and direct
• Human Resources
service functions of an
Development
organization
• Community &
Consumer
Participation
• Facilitation of a Broad
Service Array
• Organizational
Infrastructure/
Supports
Direct Service
Domain/Function
Access
The ability to
enter, navigate,
and exit
appropriate
services and
supports as
needed
Utilization
Availability
Having services
and supports in
sufficient range
and capacity to
meet the needs
of the populations
they serve
The rate of use
or usability of
appropriate
mental health
services
Organizational/System Implementation Domains for Improving Cultural Competence
The Infrastructure domain is made up of multiple
functions that are typical of organizations, each of
which must be adapted for cultural competence.
•
•
•
•
•
•
•
•
Infrastructure
Domain/Function
Organizational Values
Policies/Procedures/
Governance
Planning/Monitoring/
Evaluation
Communication
Human Resources
Development
Community &
Consumer
Participation
Facilitation of a Broad
Service Array
Organizational
Infrastructure/
Supports

Organizational values, policies, procedures
and governance contribute to cultural
competence when they promote compatibility
with the community served and provide support
for staff to carry out needed culturally
competent service practices

Likewise, planning and evaluation processes
contribute to cultural competence when they
include communities of color as fully
contributing partners with shared
responsibilities, and when they collect data that
reflects the diversity of the community
Organizational/System Implementation Domains for Improving Cultural
Competence
•
•
•
•
•
•
•
•
Infrastructure
Domain/Function
Organizational Values
Policies/Procedures/
Governance
Planning/Monitoring/
Evaluation
Communication
Human Resources
Development
Community &
Consumer
Participation
Facilitation of a Broad
Service Array
Organizational
Infrastructure/
Supports

Communication that supports cultural competence
includes two-way communication and learning within
the organization and between the organization and the
community

Human resources and service array domains
include strategies to increase bilingual/bicultural
capacity, recruitment, and retention, and availability of
services that are appropriate and of high quality for the
target population

Methods of outreach to communities and opportunities
for community/consumer participation are
important mechanisms that can lead to greater
compatibility

Organizational infrastructure can promote cultural
competence by bringing in financial, technological and
other needed resources
Organizational/System Implementation Domains for Improving Cultural Competence

Access is defined as mechanisms that facilitate
entering, navigating, and exiting appropriate
services and supports as needed (Number of Studies:
11 African-American; 8 Latino; 4 Asian, Pacific, and Islander; 3
Native American)

Availability is defined as having services and
supports in sufficient range and capacity to meet
the needs of the populations they serve. This may
include availability of bilingual personnel and/or
trained translators (Number of Studies: 9 AfricanAmerican; 10 Latino; 6 Asian, Pacific, and Islander; 6 Native
American)

Utilization is defined as the rate of use of
services or their usability for populations served.
Utilization may include issues such as length of
time in service, retention, or dropout rates (Number
of Studies: 20 African-American; 18 Latino; 6 Asian, Pacific, and
Islander; 6 Native American)
Direct Service
Domain/Function
Access
The ability to
enter, navigate,
and exit
appropriate
services and
supports as
needed
Utilization
Availability
Having services
and supports in
sufficient range
and capacity to
meet the needs
of the populations
they serve
The rate of use
or usability of
appropriate
mental health
services
Organizational/System Implementation Domains for Improving Cultural Competence
Level of compatibility can facilitate or
impede utilization of services

Direct Service
Domain/Function
Infrastructure
Domain/Function
• Organizational
Values
• Policies/Procedure
s/ Governance
• Planning/Monitorin
g/ Evaluation
• Communication
• Human Resources
Development
• Community &
Consumer
Participation
• Facilitation of a
Broad Service
Array
• Organizational
Infrastructure/
Supports
Access
The ability to enter,
navigate, and exit
appropriate services
and supports as
needed
Compatibility between
the infrastructure and
direct service functions
of an organization
Utilization
The rate of use or
usability of
appropriate mental
health services
Availability
Having services and
supports in sufficient
range and capacity to
meet the needs of the
populations they
serve
Example: Increased access
through a one-stop family
services center mechanism
may be offset by lack of
availability of bilingual
services and lack of trust in
an organization that is not
connected with the
community. This lack of trust
or bilingual capacity will
result in no increase in
utilization.
Organizational/System Implementation Domains for Improving Cultural Competence
Infrastructure
Domain/Function
• Organizational Values
• Policies/Procedures/
Governance
• Planning/Monitoring/
Evaluation
Compatibility between the
• Communication
infrastructure and direct
• Human Resources
service functions of an
Development
organization
• Community &
Consumer
Participation
• Facilitation of a Broad
Service Array
• Organizational
Infrastructure/
Supports
Direct Service
Domain/Function
Access
The ability to
enter, navigate,
and exit
appropriate
services and
supports as
needed
Utilization
Availability
Having services
and supports in
sufficient range
and capacity to
meet the needs
of the populations
they serve
The rate of use
or usability of
appropriate
mental health
services
Defining Disparities
Mental Health Focused Approach
To Defining Disparities

Eliminating Mental
Health Disparities
Leads to focus on mental
health

Access

Quality

Problem is that social
inequities exist and that there
is a relationship between
social inequities and mental
health

Everyone has a mental health
disparity
Aligned Approach:
What are the implications for solutions to
reducing mental health disparities?

Problem with the single sector definition
approach. For example, the presence of overrepresentation in other sectors
Eliminating
Mental Health
Disparities

Over-representation in:


Question then
becomes how
do these two
areas come
together?

Juvenile Justice
Child Welfare
Education
Aligned Approach:
What are the implications for solutions to
reducing mental health disparities?
Eliminating
Mental Health
Disparities
How do
these
areas
come
together?
Over-representation in
Juvenile Justice:

Youth of color make up the majority of
youth held in public and private
facilities and are a much larger
proportion of youth in public than
private facilities (which tend to be less
harsh settings)

When charged with the same offenses, African American youth with no
prior admissions were six times more likely to be incarcerated than White
youth. Latino youth were three times more likely than White youth to be
incarcerated

African American youth were confined on average for 61 days longer than
White youth, and Latino youth were confined 112 days longer than White
youth
From: Casey Family Programs
Aligned Approach:
What are the implications for solutions to
reducing mental health disparities?
Eliminating
Mental Health
Disparities
How do
these
areas
come
together?
Over-representation in
Child Welfare:



35% of the children in foster care
are African American, but they
make up only 15% of the child
population
39% of the children in foster care
are Caucasian, while they
represent 59% of the child
population
On September 30, 2003 over fifty percent (59% or 304,910) of the
523,085 children living in foster care placements were children of
color, although they represented only 41% of the child population in
the United States
From: Casey Family Programs
Aligned Approach:
What are the implications for solutions to
reducing mental health disparities?
Eliminating
Mental Health
Disparities
How do
these
areas
come
together?
Over- and Under-representation
in Education:

Among all students, AfricanAmerican students are more likely
to be suspended or expelled than
their white peers (40% vs. 15%)

African-American preschoolers
were about twice as likely to be
expelled as White and Latino
preschoolers and over five times as
likely as Asian-American
preschoolers
From: Children’s Mental Health Facts for Policymakers. By: Rachel Masi and Janice Cooper. Publication Date: November 2006.
Online at: http://nccp.org/publications/pub_687.html#10
Why Is The Conversation
So Confusing?

Some speak and focus on social disparities

Some speak and focus on mental health
disparities

Others are concerned with over-representation

Yet others are concerned about underrepresentation (Drop-out/Gifted, Etc.)
Why Is The Conversation
So Confusing?


When we talk about disparity issues, we often
confuse sectors, their solutions, and their goals

Holistic solutions are few since each sector focuses on
it’s particular goals and solutions

Solutions are elusive because the concerns and issues
facing different populations are inter-connected
What is the inter-relationship between sectors
and the social concerns they are focused upon?
Why Is The Conversation
So Confusing?
Unrelated Solutions, Sectors, and Their Goals
Mental Health
Disparity

Quality

Appropriate

Access
OverRepresentation

Social control
sectors, special
education
Social Inequities
UnderRepresentation

EducationDrop-Out

Racism

Economics

Housing

Transportation
Aligned Approach
Linked Goals
Eliminating
Mental
Health
Disparities
and Beyond
Reducing
OverRepresentation
in Other
Sectors
This leads to planning and “solution making” that:
 Focuses on a community as a whole
 Focuses on the linkages across sectors
Aligned Approach
Social Inequities: Economic, Job, Housing, and Racism/Discrimination
Reducing
Over-Representation in
Juvenile Justice
Eliminating
Mental Health
Disparities
Linked Goals
Reducing
Over-Representation in
Child Welfare
Reducing
Over- and UnderRepresentation in Education
Example Of A New Definition

Within a community-context, the goal of
eliminating mental health disparities and
beyond, must be linked to the elimination of the
over-representation of children and youth in
Juvenile Justice, Child Welfare, and Education
in order to support the wellbeing of children and
their families
Consequences Of
Untreated Mental Illness

"While mental disorders may touch all
Americans either directly or indirectly, all do not
have equal access to treatment and services.
The failure to address these inequities is being
played out in human and economic terms
across the nation – on our streets, in homeless
shelters, public health institutions, prisons and
jails."
United States Surgeon General Press Release: Sunday, August 26, 2001 http://mentalhealth.samhsa.gov/cre/release.asp
In Summary

Operationalize cultural competence

Unify solutions

Focus on broad outcomes
References

Cross, T., Bazron, B., Dennis, K., & Isaacs, M. (1989). Toward a culturally competent system of
care: A monograph on effective services for minority children who are severely emotionally
disturbed. Washington, DC: National Technical Assistance Center for Children’s Mental Health.

Hernandez, M. Nesman, T., Isaacs, M., Callejas, L. M., & Mowery, D. (Eds.). (2006). Examining
the research base supporting culturally competent children’s mental health services. Tampa, FL:
USF, Louis de la Parte Florida Mental Health Institute, Research & Training Center for Children’s
Mental Health.

Kao, H. S., Hsu, M. T., & Clark, L. (2004). Conceptualizing and critiquing culture in health
research. Journal of Transcultural Nursing, 15, 269-277.

Masi, R., & Cooper, J. (2006, November). Children’s Mental Health Facts for Policymakers.
http://nccp.org/publications/pub_687.html#10

Takaki, R. (1993). A different mirror: A history of multicultural America. Boston, MA: Little, Brown
and Company.

United States Surgeon General Press Release: Sunday, August 26, 2001.
http://mentalhealth.samhsa.gov/cre/release.asp

U.S. Department of Health and Human Services [DHHS]. (1999). Mental health: A report of the
Surgeon General. Rockville, MD: Author.