King Davis, Ph.D. Robert Lee Sutherland Chair in Mental Health & Social Policy

1. Cultural Competence andAfrican Americans with Mental Illness The President’s Commission on Mental HealthAugust 6, 2002 King Davis, Ph.D. Robert Lee Sutherland Chair in Mental Health & Social Policy School of Social Work, University of Texas at Austin Co-Chair of the National Leadership Council on African American Behavioral Healthcare, Inc.

2. Introduction • I am here today representing the National Leadership Council on African American Behavioral Health. The Council is an organization of African American consumers, family members, providers, professional associations, government staff, ministers and university professors that was formed close to one year ago. Each of the mental health disciplines is represented.

3. Introduction (cont.) • The Leadership Council is the first non-profit organization of its kind in our community that brings so many African American groups, involved in behavioral health, to the same table under a single umbrella. We work collaboratively with similar organizations from the Asian-Pacific Islander, Latino, and Native American communities. • Our interest today and focus is cultural competence as a tool for change.

4. Why is Cultural Competence Important? • Potential Cost Savings: people & dollars • a. Excess use of inpatient d. >Diagnostic error • b. High rates of recidivism e. >Insurance rates • c. Under-use of outpatient f. LOS • Ethical Base of Professions • Quality of Care Demands it • Potential Improvement in Diagnosis • Potential Improvement in Treatment • Potential for Prevention • Potential for Increasing Participation in Policy

5. Dilemmas of Mono-Cultural Service Design Source: Davis, King (2001). In Veeder & Peebles-Wilkins, London: Oxford University Press.

6. What is Culture? • Ways of behaving shared by human groups, which taken as a whole, constitute their culture. Each human society has its own culture, distinct in its entirety from that of any other society (Beals & Hoier, 1959) • The learned patterns of behavior and thought characteristic of a societal group (Harris, 1985).

7. Basic Assumption • Culture is an important variable in determining how people (consumers & providers) see and interpret (know) the world around them and the basis of how they make decisions.

8. Defining Cultural Competence • Clinical Based Definition • Cultural competence is a set of behaviors, attitudes, and policies that come together in a system, agency, or among professionals that enable them to work effectively in cross-cultural situations. Source: Cross et al. (1989).

9. Defining Cultural Competence (2) • Need-Based Definition Cultural competency is the acceptance and attention to the dynamics of difference, the ongoing development of cultural knowledge, and the resources and flexibility within service models to meet the needs of minority populations. Source: Cross et al. (1989).

10. Defining Cultural Competence (3) • Market-Based Definition • Cultural competence is the integration and transformation of knowledge, information, and data about individuals and groups of people into specific clinical standards, skills, service approaches, techniques, and marketing programs that match the individual’s culture and increase the quality and appropriateness of health care and outcomes and lowers costs. Source: Davis, King (1997).

11. Applying Cultural Competence • Domains • 1. Needs Assessment • 2. Information Exchange • 3.Service Design & Standards • 4. Human Resource Development • 5. Policies and Plans • 6. Measurement of Outcomes

12. Historical/Current Disparities1760 -2002 Workforce Composition Epidemiological Study Voluntary Participation Involvement in Policy Shortage of Outcome Studies Research Involvement (directors) Location of Services Help Seeking & Utilization Patterns Homelessness Dual-diagnosis Errors in Diagnosis Family/Consumer Experiences in System Theory & Training Foci: Immunity/Over-use • >Diagnosis of Severe Illness • Frequency of Re-Admissions • Frequency of Involuntary Admissions • Utilization of Inpatient Services • Death Rates in Hospitals • Length of Stay • Higher Dosages of Medication • Knowledge/Information • Stigma/Fear/Myth • Use of Outpatient Services • <Use of Standard Treatments Sources: Neighbors et al (2002); Snowden et al (2001) and others (see bibliography).

13. Prospective Frequency Of Illness Source: Davis, King., Johnson, Toni, & McClendon,A. (2002). Guidebook. Baltimore: Casey Foundation Mental Health: A Report of the Surgeon General, DHHS, 1999.

14. Admissions per 100,000 by Race, Ethnicity & Type of Facility Manderscheid, R. (1985). Mental Health United States. Rockville: NIMH

15. Involuntary Admissions by Race Source: Ramm, D. (Fall, 1989). Overcommitted. Southern Exposure, 14-17.

16. Policy Actions Needed • Priority on MH of Populations of Color National Action Conference • Cultural Competence Standards Licensure Requirements • Consumer/Family Participation Participation on Panels • Shift to a Disability Model New Research Scales • Involvement in Research Church Linkages • CC in Federal Agency Policy Alternative Theory • Family Education Programs Consumer Education Programs MH Services in Jails Priority on Prevention • Parity Legislation Newsletters/Clearinghouse • Revisions of Execution Policies and MI MH Policy Study Centers • Continuing Education Requirements Stigma Reduction Studies • Funded Demonstration Projects Revised University Curricula • Focused Distribution of Research Funds Services for Children • Enhanced primary care Online Sources Source: National Planning Meeting on African American Mental Health (in press); Report of National Leadership Council on African American Behavioral Health (2002).

17. Who Uses Cultural Competence? • Coca Cola/Pepsi Cola Department of Defense • Budweiser NCQA • General Motors JCAHO • IBM Managed Health Care • Time Warner California DMH • HMOs Texas DMHRM • Disney Europe Virginia DMHMR

18. National Planning Report Source: National Leadership Council on African American Behavioral Health (2002). http://www.utexas.edu/ssw/faculty/davis/naamh.pdf

19. Development of Standards

20. Quick Guide to Implementation Source: The Hogg Foundation for Mental Health, University of Texas at Austin

21. Future Research • Conceptualization of cultural competence: determination of working concepts; • Outcomes from studies in which cultural competence is applied and where it is not; • Cost of applying cultural competence & potential budgetary savings; • Differences in outcomes from different approaches to cultural competence.

22. Conclusions • Medical and psychiatric assessments have a high error rate when applied to minority populations; • Cultural competence appears to approve assessment quality and accuracy; • Contributions of cultural competence require additional research; • Adoption of cultural competence will require extensive continuing education and revisions in professional education.