Mental health and substance abuse issues affect people in every city and neighborhood in America. Most people know someone who has struggled with symptoms of a mental illness or addiction to a substance, and many people have lost a loved one to suicide. It takes a great deal of courage to seek help for mental health and substance use problems, and it’s very frustrating to run into barriers that prevent or delay access to treatment. The healthcare system can be overwhelming and confusing and can discourage people for seeking help. Additionally, some have no insurance or are underinsured, while others avoid treatment because of fear of the stigma that still exists about mental illness and substance use disorders. Still others do not feel safe or understood by behavioral health providers because of lack of cultural competence or diversity of treatment providers.
Everyone deserves access to high quality, culturally competent, and affordable behavioral healthcare. But accessing treatment for these issues can be challenging for many people in America. For example, we know that minority and underserved communities may underutilize behavioral healthcare for a variety of reasons. According to The President’s New Commission on Mental Health (2012), racial and ethnic minority Americans are projected to make up more than 40% of the population by 2025. While efforts continue to ensure that diverse populations are able to receive services that meet their needs, many barriers to access still exist. Increasing outreach and education to minority and underserved communities, increasing the diversity of behavioral health providers, and improving cultural competence in healthcare will help to engage those who are not getting the treatment services they need.
Reaching Out to Communities
It’s essential that behavioral health providers reach out to minority and underserved communities in their areas. They must understand the needs of their communities and put practices, processes, and systems in place that increase the accessibility and quality of their services. The more involved providers are in their communities, the more likely it is that they will be able to engage people who may be less likely to access behavioral health services. The National Alliance on Mental Illness (NAMI), recommends that outreach on a community level should include these steps and activities:
- Learn as much as possible about the community and try to understand the community’s awareness and perception of mental illness. This also includes learning about the community’s history, art, values, norms, language, family systems, and socioeconomics (NAMI,2014).
- Find out if the community has information about mental illness, and if they see mental illness and access to treatment as important issues.
- Explore levels of stigma about mental illness in the community.
- Identify key community leaders and work with behavioral healthcare. Cultivate these relationships and take time to build trust and gain support.
- Partner with community organizations to increase outreach possibilities.
- Focus on the type of outreach the community really needs with education programs, advocacy, or support groups.
- Get information out by working with local community organizations, including churches, clubs, libraries, stores, local media, libraries, and clinics.
- Enlist healthcare providers in underserved communities to help with outreach and education.
- Lobby state government for increased funding for behavioral services in underserved communities (Diversity, Inclusion, and Nondiscrimination, 2014).
Learning about the needs of underserved and minority communities helps behavioral healthcare providers develop effective services and increases the utilization of those services. Institutions and treatment providers must be aware of the needs of their own communities, and they must be able to engage and work effectively with individual clients and families.
Engaging Clients from Diverse Backgrounds
We know that minority populations experience rates of mental illness that are similar to those of Caucasians, but they are more likely to also experience challenges related to poverty, violence, and discrimination, which can also increase symptoms of mental illness or substance abuse. Unfortunately, members of some minority groups, including African Americans and Latinos, are more likely to delay seeking treatment for behavioral health issues until they are experiencing severe symptoms, which may mean a worse prognosis for recovery (Demler, 2012).
Additionally, research has found that people in racial and ethnic minority groups are more at risk of receiving inappropriate or inadequate treatment, including medication treatment, compared to non-minority groups. Many factors may contribute to this disparity in the quality of care, but lack of income and insurance seem to be primary reasons for the inequity. African Americans and Hispanic Americans are also less likely to receive preventative care, or early interventions, because they are more likely than white Americans to rely on clinics and hospitals for primary care (Demler, 2012). This means their symptoms may be much worse and more difficult to treat when they do attempt to access the care they need.
Culturally competent care is essential to ensure that every client that presents for treatment has the best possible experience with the behavioral healthcare system. The first step is simply awareness that culture plays a crucial role in illness, treatment, and wellness. Providers must maintain awareness of and sensitivity to things like:
- How behavioral health symptoms manifest (e.g. described as physical symptoms)
- Verbal and non-verbal communication
- Military Service History
- Financial Status
- Legal History
- Language/ need for interpreter
- Living Situation
- History of trauma
- Reasons for seeking help, and ways of seeking help
- Perceptions of medical providers and healthcare, in general
- Stigma about mental illness/ substance use disorders
- Perceptions about mental illness / substance use
- Explanations for symptoms and illness
- Strategies to cope with symptoms of mental illness
- Family/ Community support (Mental Health and Diverse Populations, 2014)
Part of being a culturally competent agency or individual treatment provider is to keep these considerations in mind when engaging minority and underserved populations. This awareness can go a long way toward preventing misunderstandings, and ensuring that clients feel respected and receive the quality care that they deserve.
Cultural Competence and Provider Diversity
In addition to thoughtful outreach and engagement efforts, it is essential that minority clients and other underserved populations (e.g. rural populations) receive culturally competent interventions. Clients may also benefit from working with providers who share their culture, when possible. Behavioral health providers need ongoing education in order to provide services that are respectful of their clients’ culture. Some individuals may not access the services they need because of barriers like these:
- Mistrust and fear of behavioral health treatment providers
- Different cultural beliefs about illness, medication, health, and recovery
- Differences in help-seeking behaviors, language, or communication patterns (including deafness or hearing impairment)
- Being uninsured or under-insured
- Discrimination/ Stereotyping by individuals and agencies
- Providers’ lack of respect for traditional remedies/interventions
- Stigma about mental illness in their own culture
- The lack of a diverse population of treatment providers (President’s New Freedom Commission, 2012)
Issues like these may prevent individuals in minority of underserved groups from seeking care. It is difficult enough to ask for help for mental health symptoms or problems with substance use, but these additional barriers can make it seem impossible. Additionally, cultural differences or lack of cultural awareness may cause treatment providers to perceive the causes of mental illness and treatment interventions very differently than their clients. For example, a national survey on clinical depression found that over 60% of African Americans believe that depression is a sign of weakness, and over 50% believe it is a natural part of the aging process. Additionally, only about 30% believe that depression is a “health problem”, and only 34% said they would take medication prescribed for depression (African American Communities and Mental Health).
Unfortunately, racial and ethnic minorities continue to be under-represented in the behavioral healthcare professions (Presidents’ New Freedom Commission, 2012). Receiving behavioral healthcare services from providers of the same or similar cultural backgrounds may help clients engage in services and have better outcomes. As many as 40% of Hispanic Americans report limited proficiency with the English language, and few can find counselors or doctors who are able to provide services in Spanish (Demler, 2012). Access to providers who speak the same language as the client can ensure the client receives an appropriate and accurate evaluation, effective treatment, and efficient crisis interventions (Hispanic-Latino Mental Health, 2014).
Despite these challenges and limitations, Dr. Robert Like of Robert Wood Johnson Medical School (2014) recommends some steps providers can take to increase their cultural competency and their effectiveness as they work with diverse populations.
- Be aware of personal beliefs, attitudes, biases and behaviors that may influence the care they provide. This also includes an awareness of interactions with colleagues from diverse backgrounds.
- Maintain humility and an openness to learning about other cultures
- Remember that while culture may provide some general information, there is no one “right” way to interact with any racial or ethnic group, and all clients are unique individuals.
- Interventions need to be evidence-based, authentic, ethical, and flexible. Approaches that are too “cookie-cutter” increase the risk of overgeneralization and stereotyping. They must be tailored to meet the needs of individual clients and their families.
- Remember that there can be just as much diversity within groups as between them
- Challenge and confront all forms of discrimination and prejudice that occur in clinical settings, as well as in society as a whole (Like, 2014).
Everyone has their own perceptions about illness, treatment and recovery, and no one can be an expert on every culture. But, behavioral health treatment providers do have the responsibility to learn as much as they can about different cultures, especially those they are most likely to serve in their community.
African American communities and mental health. (2014). Retrieved November 1, 2014, from http://www.mentalhealthamerica.net/african-american-mental-health
Demler, T. L., PharmD. (2012). Cultural competence in behavioral healthcare. Retrieved November 5, 2014, from http://www.uspharmacist.com/continuing_education/ceviewtest/lessonid/108684/
Diversity, inclusion, and non-discrimination. (2014). Retrieved October 30, 2014, from http://www.nami.org/Content/NavigationMenu/NAMI_Center_for_Excellence/Tools_for_Excellence/Diversity_and_Inclusion_Tools.htm
Hispanic-Latino Mental Health. (2014). Retrieved October 31, 2014, from http://www.psychiatry.org/mental-health/people/hispanics-latinos
Like, R. C., M.D. (2014). Cultural competence pointers. Retrieved November 6, 2014, from http://erc.msh.org/mainpage.cfm?file=2.4.htm&module=provider&language=English
Marsella, A., PhD. (2011, October). Twelve critical issues for mental health professionals working with ethno-culturally diverse populations. Psychology International Newsletter. Retrieved November 2, 2014, from http://www.apa.org/international/pi/2011/10/critical-issues.aspx
Mental health and diverse populations at a glance. (2014). Retrieved November 2, 2014, from http://www.psychiatry.org/practice/professional-interests/diversity/diversity-month/mental-health-and-diverse-populations-at-a-glance
President's New Freedom Commission on Mental Health. (2012). Retrieved October 30, 2014, from http://www.nami.org/Content/NavigationMenu/Inform_Yourself/About_Public_Policy/New_Freedom_Commission/Goal_3_Disparities_in_Mental_Health_Services_Eliminated.htm