Promoting and supporting Culturally Appropriate Children's Mental Health Services

1. Promoting and supporting Culturally Appropriate Children's Mental Health Services The World Federation for Mental Health on Transcultural Mental Health: Building a Global Response Minneapolis, Minnesota - October 30, 2007 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

2. 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?”

3. 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

4. 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)

5. 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)

6. 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).

7. 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).

8. Maslow’s Hierarchy Of Needs: Humanistic Theory Self Actualization Culture: Esteem and Identity Love and Belonging The way we go about meeting our needs Safety and Security Physiologic (e.g., Food, Water) (Cross, Bazron, Dennis, & Isaacs, 1989)

9. Assumption • Culture influences most, if not all, aspects of human social interactions

10. Although culture is omnipresent, it is frequently invisible, especially to those enmeshed within a particular culture

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. Cultural Competence

20. 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

21. 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.

22. 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

23. Summary Of Cultural Competence Continuum • Cultural Destructiveness • Cultural Incapacity • Cultural Blindness • Cultural Pre-Competence • Cultural Competence • Advanced Cultural Competence

24. 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.

25. 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”

26. 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

27. 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

28. 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

29. 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

30. 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

31. Defining Organizational Cultural Competence

32. Background:Defining Cultural Competence • Cultural competence has remained largely an ideology with a set of guiding principles that lack clear operationalization (Vega & Lopez, 2001)

33. 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). Community Context Cultural/Linguistic characteristics of a community’s population Degree of compatibility defines level of organizational/systemic cultural competence Outcomes: Reducing mental health disparities Compatibility Organization’s/System’s Direct Service Domain/ Functions Infrastructure Domain/ Functions Hernandez, M., & Nesman, T. (2006).

34. Characteristics Of TheCommunity Population • Cultural View of Mental Health • History • Language Characteristics • Resource Characteristics • Strength Characteristics • Needs Characteristics Cultural/Linguistic characteristics of a community’s population Compatibility An organization’s/system’s combined policies, structures and processes

35. 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). Community Context Cultural/Linguistic characteristics of a community’s population Degree of compatibility defines level of organizational/systemic cultural competence Outcomes: Reducing mental health disparities Compatibility Organization’s/System’s Direct Service Domain/ Functions Infrastructure Domain/ Functions Hernandez, M., & Nesman, T. (2006).

36. Organizational/System Implementation Domains for Improving Cultural Competence Infrastructure Domain/Function Direct Service Domain/Function Access The ability to enter, navigate, and exit appropriate services and supports as needed • 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 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

37. 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 governancecontribute 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 evaluationprocesses 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 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

38. Organizational/System Implementation Domains for Improving Cultural Competence • Communicationthat supports cultural competence includes two-way communication and learning within the organization and between the organization and the community • Human resourcesand service arraydomains 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 participationare important mechanisms that can lead to greater compatibility • Organizational infrastructurecan promote cultural competence by bringing in financial, technological and other needed resources 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

39. 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) Direct Service Domain/Function Access The ability to enter, navigate, and exit appropriate services and supports as needed 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

40. Organizational/System Implementation Domains for Improving Cultural Competence • 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 Access The ability to enter, navigate, and exit appropriate services and supports as needed • 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 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

41. Organizational/System Implementation Domains for Improving Cultural Competence Infrastructure Domain/Function Direct Service Domain/Function Access The ability to enter, navigate, and exit appropriate services and supports as needed • 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 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

42. Defining Disparities

43. 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

44. 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 • Over-representation in: • Juvenile Justice • Child Welfare • Education Eliminating Mental Health Disparities • Question then becomes how do these two areas come together?

45. 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) Aligned Approach: What are the implications for solutions to reducing 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 Eliminating Mental Health Disparities From: Casey Family Programs

46. 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 Aligned Approach: What are the implications for solutions to reducing mental health disparities? • How do these areas come together? Eliminating Mental Health Disparities • 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

47. 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 Aligned Approach: What are the implications for solutions to reducing mental health disparities? • How do these areas come together? Eliminating Mental Health Disparities 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

48. 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.)

49. 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?

50. Why Is The Conversation So Confusing? Unrelated Solutions, Sectors, and Their Goals • Social Inequities • Racism • Economics • Housing • Transportation Over-Representation • Social control sectors, special education Under-Representation • Education- Drop-Out Mental Health Disparity • Quality • Appropriate • Access