Eliminating Disparities in Mental Health Care: Practice Level Interventions
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Additional Resources: |
Callejas, L.M., Martinez, K. (2009, October 15.) Community-Defined Evidence: Research from the Ground Up. Presented in October Forum, National Network to Eliminate Disparities in Behavioral Health, Online. This PowerPoint presentation addresses the growing gaps between whites and people of color in the mental health field in an atmosphere focused on evidence-based practices which may not be applicable to all populations and communities. Alternatively, the authors discuss community defined evidence, to define practices that may not have been measured empirically but have been shown to have positive results within a community over time. The Community Defined Evidence Project aims to gather expert feedback on a model for establishing evidence for those practices. Gamache, P., & Lazear, K.J. (2009). Asset-based approaches for lesbian, gay, bisexual, transgender, questioning, intersex, two-spirit (LGBTQI2-S) youth and families in systems of care. (FMHI pub. No. 252). Tampa, FL: University of South Florida, College of Behavioral and Community Sciences, The Louis de la Parte Florida Mental Health Institute, Research and Training Center for Children’s Mental Health. A monograph focusing on three main goals: 1) to review the literature on LGBTQI2-S youth and their families, 2) to provide a framework that can be used to explore an organization’s compatibility with the needs of LGBTQI2-S youth, and 3) to identify gaps in the literature and suggest next steps for research. Isaacs, M., Huang, L.N., Hernandez, M., and Echo-Hawk, H (2005). The Road to Evidence: the Intersection of Evidence-Based Practices and Cultural Competence in Children's Mental Health. Bethesda, MD: The National Alliance of Multi-Ethnic Behavioral Health Associations. Both evidence-based practices and cultural competence are increasingly being recognized as important focuses for children’s mental health policy and practice. However, this paper acknowledges the separation between these two significant elements of creating effective policy and practice. It discusses the reasons for the lack of intersection between these movements and suggests ways of merging those factions. Lieberman, R., Martinez K., Zubritsky, C., Fisher, S., Kramer, T., Koch, R., Obrochta, C., Moore, K. (2009). Issue Brief: Critical Policy Issues in the Implementation of Evidence Based Practices. Outcomes Roundtable for Children and Families (ORCF). This issue brief addresses the implications surrounding the use of evidence-based practices (EBPs) for children, youth, and families. As EBPs emerge in the children’s mental health field, difficulties arise associated with applying those practices to diverse communities. There are varying perspectives about and challenges to using EBPs, including reconciling conflicting definitions, ensuring evaluation and data collection to sustain practice effectiveness, and adapting EBPs to new contexts. By describing some of those challenges, the ORCF hopes to stimulate culturally competent, as well as data-driven, improvements in policy and services for children and adolescents with emotional and behavioral health needs. Poirier, J.M., Francis, K.B., Fisher, S.K., Williams-Washington, K., Goode, T., & Jackson, V H. (2008). Practice Brief 1:Providing Services and Supports for Youth who are Lesbian, Gay, Bisexual, Transgender, Questioning, Intersex, or Two Spirit. Washington, DC: National Center for Cultural Competence, Georgetown University Center for Child and Human Development. This brief provides information on how to develop culturally and linguistically competent services for LGBTQI2-S youth. Aimed towards policymakers, administrators, and providers, it addresses the needs of such youth and offers resources and strategies for creating a welcoming environment. Ryan, C. (2009). Helping Families Support Their Lesbian, Gay, Bisexual, and Transgender (LBGT) Children. Washington, DC: National Center for Cultural Competence, Georgetown University Center for Child and Human Development. The amount of resources available to LGBT individuals has increased over the past couple of decades, but many families are unsure of how to support their LGBT children and adolescents, and help them access those resources. This brief discusses research from the Family Acceptance Project that shows the influence of family acceptance on children’s mental health and well-being. Waidmann, Timothy (2009.) Estimating the Cost of Racial and Ethnic Mental Health Disparities. Washington, DC: The Urban Institute. Cost burdens of racial and ethnic disparities are likely to increase significantly with time. This article assesses those costs by examining preventable disease, specifically, diabetes, hypertension, and stroke, in African American and Latino communities. Fluctuations in shifting population demographics add an additional variable to these increasing expenses. Results estimate that the total cost of disparities to Medicare and Medicaid will arise to over $50 billion by 2050. October 15, 2009 Call #1 of Series – Elimination of Disparities in Mental Health Care: An Overview November 11, 2009 Call #2 of Series – Elimination of Disparities in Mental Health Care: At the Organizational and Systems Level |
This call will direct its attention to the search for the “right intervention” for persons from historically and currently marginalized populations. Ken Martinez calls for us to think carefully and cautiously about the application of “evidence-based practices” with populations on whom the interventions have not been normed. He further guides us to consider the research efforts to discover and understand practices based on “community defined evidence.” Holly Echo-Hawk continues the discussion with review of work to identify culturally based practices for Pacific Islander and Indigenous populations of America. Caitlin Ryan proposes intervention strategies that could dramatically impact the prevalence of serious mental health and substance abuse challenges of youth who are lesbian, gay, bisexual or transgender. Finally, Henry Gregory invites us to examine an Africentric intervention approach that is derived from the world view of pre-colonial Africa. In each case, there is a search for an approach that may resonate more closely to culturally informed notions of problem definition and approaches to the helping relationship.
Strategies to Address Disparities in Mental Health Care: Improve Access - But Access to What? Does the Intervention Work for Me?
By Vivian H. Jackson, Ph.D.,
Senior Policy Associate, National Center for Cultural Competence, National Technical Assistance Center for Children’s Mental Health, Georgetown University Center for Child and Human Development
Multiple factors contribute to mental health disparities. Stigma or mental health beliefs of some cultural groups interfere with their seeking of care, while for others, the negative attitudes of some practitioners discourage them from seeking care. The lack of cultural knowledge may lead some practitioners to stumble into errors in their relationships, their assessments, and/or their interventions. Organizational and systemic factors, such as policies, financing strategies, workforce recruitment and preparation, and contract management, can reinforce existing disparate care for historically and currently marginalized populations. Even so, much of the discussion regarding addressing disparities in mental health care has had a focus on access. For example, the New Freedom Commission on Mental Health (2003) suggested that the primary strategies to address racial and ethnic disparities are 1) increased access to services 2) a greater number of racial and ethnic minority practitioners. Perhaps with the right health benefits, an increase in the number and convenience of conventional mental health services, and an increase in the number of persons from the same cultural backgrounds to provide those services, mental health disparities would be corrected.
While addressing is access is important, attention to some of the other elements that contribute to disparities is important as well. Access is a necessary but insufficient condition to achieve elimination of disparities in mental health care. One crucial question to address is whether or not the intervention that is offered is an intervention that will be effective in addressing the emotional and behavioral distress of the particular child or youth, his or her family, and the larger community for whom it is being proposed. Is it the “correct” intervention? Does the intervention address the concerns that lead the child or family to come into contact with mental health services? These could be physical signs or symptoms; indicators of emotional distress; problematic behaviors, problems in relationships with family members, friends or other youth or adults; inability to fulfill socially expected roles at school, in play, or in community activities; violation of community norms; or violation of norms within the cultural community. The practitioner, child or youth, and family are challenged to identify approaches to assess the issues and develop an approach that will address the needs of that family unit. The mental health field has developed numerous assessment tools and there is a growing number of “evidence-based practices” that have been developed to help answer these questions. The practitioner, child or youth, and family are again faced with the question of how well or how poorly these tools fit the cultural contexts of those being served.
Culture Matters
Mental health services are not provided in a neutral or sterile environment. Service goals and processes are embedded in culture – beliefs, traditions, practices, norms, values. It is easy to assume that the values, beliefs about the source of knowledge, and assumptions about the processes of life are the same from culture to culture. But they are not, and to a greater or lesser degree, the interventions developed and promulgated in the United States are grounded in a Western European values and belief system. The degree to which these interventions can be expected to be effective depends in part on the degree to which they are compatible with the beliefs, traditions, practices, norms and values of the service population as a group, as well as with the particular child, youth and family of focus (Hernandez, et. al., 2006). If the cultural norms give “family” greater value than “individual,” an intervention that focuses on the individual without regard for the impact on the family may not be well received and may prove to be ineffective. Should the practitioner label the family as noncompliant, or should there perhaps be an examination of the intervention goals and approach?
Consider the impact of culture on the beliefs relevant to a helping service. Culture influences the client’s perspective on goals for services, help-seeking patterns, determinations of who is a legitimate helper, what the appropriate roles are for the helper and helpee, what the appropriate strategies are for problem-solving or solution-finding, and the definition of success (Bordin, 1979, Julia, 1996).The expectations that clients have for the helping encounter are informed by both the traditions of their culture and the nature of the historical and current interactions between the involved groups. The anticipation of a “welcoming’ or “hostile” service environment will influence the client’s approach to that service. If the service organization has a history of discrimination and prejudice, current offers of help will need to address that negative history if the organization is to be regarded as a legitimate provider of services in the present and future. (Jackson, 2008)
Participation Matters
Not only is it necessary for the practitioner to offer the correct intervention, but the child or youth and the family must also be actively engaged in that intervention to maximize the possibility of a positive outcome. The level and quality of that engagement is first dependent on the degree to which there is congruence on the goals and methods to achieve the goals. While the agency, practitioners, and other service providers including family partners make the offer “to help” resolve the problematic issues, the client must first perceive, recognize, or label the offer as “an invitation to be helpful”. The client must then interpret the offer as being “potentially helpful” before he or she is willing to “act” or participate in the process. The successful negotiation of subsequent roles, responsibilities, and actions between the practitioner and the client influence subsequent levels of participation. (Jackson, 2008)
The right environment creates the preconditions for meaningful participation (i.e., participation by client such that they experience themselves as partners in the service process). Littell (2001) introduces participation as a term that captures and extends the concepts we know of as therapeutic alliance, engagement, and compliance. It is based on the recognition that helping services require an energy investment on the part of the client. Service is not a unidirectional endeavor on behalf of the practitioner towards the client. It requires emotional, cognitive and physical energy on the part of the client. Participation as a concept captures the degree to which the client uses this energy in partnership with the helping system to promote resilience or find recovery. According to Littell, the combination of 1) cognitive, emotional and physical engagement of the client, 2) the appropriate intervention, 3) positive interaction between client and provider, and 4) necessary resources will maximize the possibilities for a positive outcome. Participation can vary on two axes, passive- active and positive to negative. If the client is positive and passive, the style may be “acquiescent”. If it is negative and positive, it may be labeled “resistant”. If it is active and negative, it might be labeled “hostile or disruptive.” Participation that is positive and active would be labeled as “cooperative.” This framework reinforces the complexity related to achieving the best outcomes.
Mental Models Matter
Another layer to consider is the imagery that each party brings to the helping encounter. Each party, the practitioner and the child, youth and family member, brings his or her own mental model regarding the nature of the relationships to the service experience. As noted above, belief systems serve as one contributing factor. There is another level that is operating in the experience. These are factors that are grounded in each person’s beliefs and attitudes about their own engagement in a helping process as a member of a cultural group. Comas-Diaz (1991) described the range of mental models that the client and that the practitioner can bring to the relationship whether of the same cultural group or of a different cultural group. Client attitude and behavior with a practitioner from a different cultural group could include, a) over-compliance, b) denial of ethnicity and culture, c) mistrust, suspicion and hostility, d) and/or ambivalence. The practitioner from a different cultural group may, a)deny the ethno cultural differences, b)take on a “clinical anthropologist syndrome” by being overly curious about client’s culture beyond what is clinically necessary, c) guilt, d) pity, e) aggression/overly confrontational, or f) ambivalence. The client may have the following responses to a practitioner of the same cultural group: a) belief in the omniscient and omnipotent helper, b) belief that practitioner is a traitor, or “selling out” the group, c) auto racist (internalized oppression) or, d) ambivalence. The practitioner of the same cultural group may: a) over identify, b) join in an “us and them” stance that engages client in an anti oppressor group mentality, c) cultural myopia by being unable inability to see the issues, d) ambivalence, e) anger towards the client (i.e., “get over it”), f) survivor’s guilt, or g) feeling a loss of hope and despair by being too overwhelmed by the cultural group’s story. Each party may hold one or more of these attitudes and beliefs as he or she engages in the discussion of the distress of the focal child or youth, the implications for the family, and the tasks required of all to achieve positive outcomes on goals that are mutually determined.
Summary
The mental health service system and system partners have an obligation to engage in the steps required to ensure that all children, youth, and their families who are experiencing emotional and behavioral distress have access to services for help. However, the nature of that help must be crafted to account for the cultural interpretation of the issues, the cultural expectations of the helping process, and the culturally oriented mental models that each party possesses in the helping relationship. Access plus the correct intervention conducted within a satisfying relationship are necessary ingredients to promote positive outcomes and reduce disparities.
References
Bordin, E.S. (1979). The generalizability of the psychoanalytic concept of the working alliance. Psychotherapy: Theory, research and practice, 16(3), 252-260.
Comas-Diaz, L. & Jacobsen, F.M. (1991). Ethnocultural transference and counter-transference in the therapeutic dyad. American journal of orthopsychiatry, 61(3), 392-402.
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: University South Florida, Louis de la Parte Florida Mental Health Institute, Research and Training Center for Children’s Mental Health.
Jackson, V. (2008). An exploratory study of the meaning of culture in family preservation and kinship care services: An Africentric translation. Cleveland, OH: Case Western Reserve University.
Julia, M.C. (Ed.). (1996). Multicultural awareness in the health care professions. Boston, MA: Allyn and Bacon.
Littell, J.H., Alexander, L.B.,& Reynolds, W.W. (2001). Client participation: Central and underinvestigated elements of intervention. Social service review, 75(1),1-28.
New Freedom Commission on Mental Health (2003). Achieving the promise: Transforming mental health care in America. Final report. Rockville, MD: US Dept Health and Human Services.
Question…
As you consider your own setting, what steps been taken to understand the cultural beliefs and perceptions regarding the emotional and behavioral distress? How has your organization shaped its program to address various cultural expectations of the helping process and interventions?
