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PROMOTING AND SUPPORTING CULTURALLY APPROPRIATE CHILDREN'S MENTAL HEALTH SERVICESMario Hernandez, Ph.D. Professor/Interim ChairDepartment of Child and Family StudiesLouis 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 ResponseMinneapolis, 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).
(Cross, Bazron, Dennis, & Isaacs, 1989)
Self
Actualization
Esteem and Identity
Love and Belonging
Safety and Security
Physiologic (e.g., Food, Water)
Maslow’s Hierarchy Of Needs: Humanistic Theory
Culture:
The way w
e go about meeting our needs
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
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
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 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 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
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
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:
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)
Cultural/Linguistic characteristics of a
community’s population
Infrastructure Domain/
Functions
Direct Service Domain/Functions
De
gre
e o
f co
mp
atib
ility
de
fine
s le
vel o
f o
rga
niz
atio
na
l/sys
tem
ic c
ultu
ral c
om
pe
ten
ce
Outcomes: Reducing mental health disparities
Compatibility
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).
Conceptual Model for Accessibility of Mental Health Services to Culturally/Linguistically Diverse Populations
Community Context
Hernandez, M., & Nesman, T. (2006).
Organization’s/System’s
Characteristics Of TheCommunity Population
Cultural View of Mental Health
History
Language Characteristics
Resource Characteristics
Strength Characteristics
Needs CharacteristicsAn organization’s/system’s
combined policies, structures and
processes
Cultural/Linguistic characteristics of a
community’s population
Compatibility
Cultural/Linguistic characteristics of a
community’s population
Infrastructure Domain/
Functions
Direct Service Domain/Functions
De
gre
e o
f co
mp
atib
ility
de
fine
s le
vel o
f o
rga
niz
atio
na
l/sys
tem
ic c
ultu
ral c
om
pe
ten
ce
Outcomes: Reducing mental health disparities
Compatibility
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).
Conceptual Model for Accessibility of Mental Health Services to Culturally/Linguistically Diverse Populations
Community Context
Hernandez, M., & Nesman, T. (2006).
Organization’s/System’s
Infrastructure Domain/Function
Direct Service 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
AccessThe ability to
enter, navigate, and exit
appropriate services and supports as
needed
AvailabilityHaving services and supports in sufficient range and capacity to meet the needs
of the populations they
serve
UtilizationThe rate of use or usability of appropriate
mental health services
Compatibility between the infrastructure and
direct service functions of an organization
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
The Infrastructure domain is made up of multiple
functions that are typical of organizations, each of
which must be adapted for cultural competence.
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
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
• Organizational Values• Policies/Procedures/
Governance• Planning/Monitoring/
Evaluation• Communication• Human Resources
Development• Community &
Consumer Participation
• Facilitation of a Broad Service Array
• Organizational Infrastructure/ Supports
Direct Service Domain/Function
AccessThe ability to
enter, navigate, and exit
appropriate services and supports as
needed
AvailabilityHaving services and supports in sufficient range and capacity to meet the needs
of the populations they
serve
UtilizationThe rate of use or usability of appropriate
mental health services
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 African-
American; 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)
Organizational/System Implementation Domains for Improving Cultural Competence
Direct Service Domain/Function
AccessThe ability to enter, navigate, and exit
appropriate services and supports as
needed
AvailabilityHaving services and supports in sufficient range and capacity to meet the needs of the populations they serve
UtilizationThe rate of use or
usability of appropriate mental
health services
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
Compatibility between the infrastructure and
direct service functions of an organization
Level of compatibility can facilitate or
impede utilization of services
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.
Infrastructure Domain/Function
Direct Service 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
AccessThe ability to
enter, navigate, and exit
appropriate services and supports as
needed
AvailabilityHaving services and supports in sufficient range and capacity to meet the needs
of the populations they
serve
UtilizationThe rate of use or usability of appropriate
mental health services
Compatibility between the infrastructure and
direct service functions of an organization
Organizational/System Implementation Domains for Improving Cultural Competence
Defining Disparities
Mental Health Focused Approach To Defining 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
Eliminating Mental Health
Disparities
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 over-representation in other sectors
Eliminating Mental Health
Disparities
Over-representation in: Juvenile Justice Child Welfare EducationQuestion then
becomes how do these two areas come together?
Aligned Approach: What are the implications for solutions to reducing mental health disparities?
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)
Eliminating Mental Health
Disparities
How do these areas come
together?
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
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
Eliminating Mental Health
Disparities
How do these areas come
together?
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?
Over- and Under-representation in Education:
Among all students, African-American 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
Eliminating Mental Health
Disparities
How do these areas come
together?
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
Aligned Approach: What are the implications for solutions to reducing mental health disparities?
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 under-
representation (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
Over-Representation Social control
sectors, special education
Under-Representation Education-
Drop-Out
Social Inequities Racism
Economics
Housing
Transportation
Aligned Approach
Linked Goals
This leads to planning and “solution making” that: Focuses on a community as a whole Focuses on the linkages across sectors
Social Inequities: Economic, Job, Housing, and Racism/Discrimination
Aligned Approach
Eliminating Mental Health
Disparities
Linked Goals
Reducing Over-Representation in
Juvenile Justice
Reducing Over-Representation in
Child Welfare
Reducing Over- and Under-
Representation 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.
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