promoting and supporting culturally appropriate children's mental health services mario...

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


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



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 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 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 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 – 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

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de

fine

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ultu

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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



Compatibility



Infrastructure Domain/

Functions

Direct Service Domain/Functions

De

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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

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om

pe

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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









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



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













needed



serve




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)



AccessThe ability to enter, navigate, and exit


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 Values

• Policies/Procedures/ Governance

• Planning/Monitoring/ Evaluation

• Communication• Human Resources







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.













needed



serve






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


Disparities

Over-representation in: Juvenile Justice Child Welfare EducationQuestion then

becomes how do these two 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)


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


Disparities


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


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


Disparities


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


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.)


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?


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


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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