The Challenge of Cultural Competence in Minority Mental Health Care

July is Minority Mental Health Awareness Month. The need for special action to provide better mental health services for minorities became increasingly apparent in the 1990s as studies demonstrated that minorities were less likely to seek treatment for mental health issues and had less success when they did (Sue, 1998). Progress in rectifying these disparities has been uneven. Some studies have pointed to the effectiveness of intervention schemes (Sue et al., 2009), whereas others have concluded “little progress has been made” (Santiago et al., 2014).

The Importance of Cultural Competence

There are two ways of approaching the issue of equality in health care. The first is to look at supply. This could involve ensuring that more affordable insurance policies include adequate provision for mental health care, placing clinics in deprived areas, and ensuring that providers are not affected by bias or prejudice.

The second approach is to look at matters from the perspective of demand. Why are members of minority groups less likely to seek treatment for mental health issues, and what causes them to drop out more frequently? It is in answer to these sets of questions that the concept of cultural competence in psychology arose.

In essence, cultural competence means providing therapy that can overcome cultural barriers between therapist and person in therapy. One side of this is acquiring specific forms of knowledge about the norms and mores of different communities. What might seem polite in one cultural setting can be perceived as aloof in another and vice versa. The more a therapist knows, the easier it is to put the person in therapy at ease and start the process of exploration and healing.

Implementing cultural competence across the profession requires that our own “culture” as mental health professionals undergoes a deep transformation, guided by academic research and a commitment to helping each individual to the best of our abilities.

However, in the more diverse cities in America, a therapist could potentially come across people from hundreds of different cultures, and mastering all the intricacies of even one could take years. Obviously, it’s not practical or realistic for every therapist to learn everything about the cultural background of every therapy seeker in advance. Taken to its extreme, such a demand would end up with a segregated mental health care system in which, for example, only Korean-American therapists could see Korean-Americans. Even such a drastic and undesirable measure would still leave out the increasingly large group of individuals who are from unique, mixed cultural backgrounds.

The other side of cultural competency, therefore, is less about knowledge than openness. When forming a therapeutic relationship with a person in therapy, a different cultural background can actually form part of the process of building the relationship, if the therapist is alert to the ubiquity of cultural difference and on the lookout for the unknown and unexpected. While we struggle as a profession to incorporate cultural awareness and sensitivity into our work, it is important to remember that people are individuals, not stereotypes. We should be guided by empirical research into what can be done to make members of different minority groups feel comfortable, but at the same time we should approach each one as a unique individual. In short, cultural competence and person-centeredness are not competing approaches, but complementary (Saha et al., 2010).

The Cultural Aspect of Diagnosis

Of course, psychotherapy is about more than getting to know someone and talking about their concerns. Our first goal as therapists is to alleviate symptoms. This points to another aspect of cultural competence, since, as we are increasingly discovering, many of the basic concepts we use to discuss mental health conditions are, in fact, highly dependent on cultural background (Viswanath and Chaturvedi, 2012). Terms such as anxiety, depression, or stress simply do not have one universally applicable meaning (Neftci and Barnow, 2016). To take an example that is increasingly relevant in the United States, the experience of depression among Hispanic immigrants is highly contingent on specific cultural factors related both to their cultural background and their immigration status.

The task of controlling for cultural biases hidden with the diagnostic framework we all use is not an easy one. As research teaches us more about the cultural nature of mental health, it is incumbent on academics to publicize their findings and for therapists to keep abreast of them.

Transforming Our Own Culture

As we mark Minority Mental Health Awareness Month, we must note soberly that the task of providing adequate mental health care for every group is not a simple one. It involves more than simply devoting resources and raising awareness, though these are certainly important. Rather, implementing cultural competence across the profession requires that our own “culture” as mental health professionals undergoes a deep transformation, guided by academic research and a commitment to helping each individual to the best of our abilities. Transformations of this kind are inevitably slow, but the rewards are there for all to see with each person who receives effective treatment. Each generation of mental health professionals has its own unique task, and I believe ours is cultural competence, cultural awareness, and cultural sensitivity.

References:

1. Balkir Neftci, N., & Barnow, S. (2016). One size does not fit all in psychotherapy: Understanding depression among patients of Turkish origin in Europe. Noro Psikiyatr Arsivi 53(1): 72-79. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/28360770
2. Saha, S. (2010). Patient centeredness, cultural competence and healthcare quality. Journal of the National Medical Association 100(11): 1275-1285. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2824588/
3. Santiago, C.D., & Miranda, J. (2014). Progress in improving mental health services for racial-ethnic minority groups: a ten-year perspective. Psychiatric Services 65(2): 180-185. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/24178249
4. Sue, S. (1998). In search of cultural competence in psychotherapy and counseling. American Psychologist 53(4): 440-448. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/9572007/
5. Sue, S., Zane, N., Nagayama Hall, G. C., & Berger, L. K. (2009). The case for cultural competency in psychotherapeutic interventions. Annual Review of Psychology 60: 525-548. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2793275/
6. Viswanath, B., & Chaturvedi, S. K. (2012). Cultural aspects of major mental disorders: A critical review from an Indian perspective. Indian Journal of Psychological Medicine 34(4): 306-312. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3662125/

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