Through employment of minority practitioners and the creation of specialized minority-oriented programs, community-based, publicly supported mental health programs have achieved greater minority representation than are found in other mental health settings (Snowden, 1999). Mental health care providers who are themselves from ethnic minority backgrounds are especially likely to treat ethnic minority clients and have been found to enjoy good success in retaining them in treatment (Sue et al., 1991).
The character of the mental health program in which treatment is provided has proven particularly important in encouraging minority mental health service use. Research has shown that programs that specialize in serving identified minority communities have been successful in encouraging minorities to enter and remain in treatment (Yeh et al., 1994; Snowden et al., 1995; Takeuchi et al., 1995; Snowden & Hu, 1996). Modeled on programs successfully targeting groups of recent immigrants and refugees, minority-oriented programs appear to succeed by maintaining active, committed relationships with community institutions and leaders and making aggressive outreach efforts; by maintaining a familiar and welcoming atmosphere; and by identifying and encouraging styles of practice best suited to the problems particular to racial and ethnic minority group members. A challenge for such programs is to meet specialized sociocultural needs for clients from various backgrounds. The track record of minority-oriented programs at improving treatment outcomes is not yet clear for adults but appears to be positive for children and adolescents (Yeh et al., 1994).
There is a specialized system of care for Native Americans that provides mental health treatment. The Indian Health Service (IHS) includes a Mental Health Programs Branch; it offers mental health treatment intended to be culturally appropriate. Urban Indian Health Programs also provide for mental health treatment. The IHS Alcoholism/Substance Abuse Program Branch sponsors services on reservations and in urban communities through contracts with service providers. Most mental health programs in the IHS focus on screening and treatment in primary care settings. Due to budgetary restraints, IHS is able to provide only limited medical, including mental health, coverage of Native American peoples (Manson, 1998).
Many tribes have moved toward self-determination and, as a result, toward assuming direct control of local programs. When surveyed, these tribal health programs reported providing mental health care in a substantial number of instances, although questions remain about the nature and scope of services. Finally, the Department of Veterans Affairs and many state and local authorities provide specialized mental health programming targeting persons of Native American heritage (Manson, 1998). Little is known about the levels and types of care provided under any of these arrangements.
Advocates and policymakers have called for all mental health practitioners to be culturally competent: to recognize and to respond to cultural concerns of ethnic and racial groups, including their histories, traditions, beliefs, and value systems (CMHS, 1998).
Cultural competence is one approach to helping mental health service systems and professionals create better services and ensure their adequate utilization by diverse populations (Cross et al., 1989). It is defined as a set of behaviors, attitudes, and policies that come together in a system or agency or among professionals that enables that system, agency, or professionals to work effectively in cross-cultural situations (Cross et al., 1989). This is especially important because most mental health providers are not racial and ethnic minority group members (Hernandez et al., 1998). Using the term competence places the responsibility on the mental health services organization and all of its employees, challenging them all to become part of a process of providing culturally appropriate services. This approach emphasizes understanding the importance of culture and building service systems that recognize, incorporate, practice, and value cultural diversity.
There is no single prescribed method for accomplishing cultural competence. It begins with respect, and not taking an ethnocentric perspective about behavior, values, or beliefs. Three possible methods are to render mainstream treatments more inviting and accessible to minority groups through enhanced communication and greater awareness; to select a traditional therapeutic approach according to the perceived needs of the minority group; or to adapt available therapeutic approaches to the needs of the minority group (Rogler et al., 1987). One effort to promote cultural competence has been directed toward mental health services systems and programs. The Center for Mental Health Services has developed, with national input, a preliminary set of performance indicators for cultural competence by which service and funding organizations might be judged. Cultural competence in this context includes consultation with cross-cultural experts and training of staff, a capacity to provide services in languages other than English, and the monitoring of caseloads to ensure proportional racial and ethnic representation. The ultimate test of any performance indicator will be documented by improvements in care and treatment of ethnic and racial minorities.
Another response has been to develop guidelines that more directly convey variations believed necessary in the course of clinical practice. An appendix to DSM-IV presents clinicians with an Outline for Cultural Formulation. The guidelines are intended as a supplement to standard diagnosis, for use in multicultural environments and for the provision of a systematic review of the individuals cultural background, the role of the cultural context in the expression and evaluation of symptoms and dysfunction, and the effect that cultural differences may have on the relationship between the individual and the clinician (DSM-IV).
The Outline for Cultural Formulation covers several areas. It calls for an assessment of cultural identity, including degree of involvement with alternative cultural reference groups; cultural explanations of illness; cultural factors related to stresses, supports, and level of functioning and disability (e.g., religion, kin networks); differences in culture or social status between patient and clinician and possible barriers (e.g., communication, trust); and overall cultural assessment.
Others have focused attention on the process by which mental health practitioners must engage, assess, and treat patients and on understanding how cultural differences might affect that process (Lopez et al., in press). Viewed from this perspective, the task is to maintain two points of viewthat of the cultural group and that of evidence-based mental health practiceand strategically integrate them with the aim of valuing and utilizing culture, context, and practice in a way that promotes mental health.
This capacity has a dual advantage. The practitioner comes to understand the problem as it is experienced and understood by the patient and, in so doing, gains otherwise inaccessible information on personal and social reality for the patient, as well as a sense of trust and credibility. At the same time the practitioner is able to plan for and implement an appropriate intervention. It is through a facility and a willingness to switch from a professional orientation to that of the client and his or her cultural group that the clinician is best able to implement guidelines for cultural competence such as those specified in DSM-IV (Mezzich et al., 1996).
In the end, to be culturally competent is to deliver treatment that is equally effective to all sociocultural groups. The treatments provided must not only be efficacious (based on clinical research), but also effective in community delivery. The delivery of effective treatments is complicated because most research on efficacy has been conducted on predominantly white populations. This suggests the importance of both efficacy and effectiveness studies on racial and ethnic minorities.
At present, there is scant knowledge about treatment effectiveness according to race, culture, or ethnicity (Snowden & Hu, 1996). Rarely has research evaluating standard forms of treatment examined differential effectiveness. In fact, the American Psychological Associations Division of Clinical Psychology Task Force, which tried to identify the efficacy of different psychotherapeutic treatments, could not find a single rigorous study of treatment efficacy published on ethnic minority clients (Chambless et al., 1996). Nor have studies been carried out on the efficacy of proposed cultural adaptations of treatment in comparison with standard alternatives. Only as more knowledge is gained will it become possible to mount a full-fledged and appropriate response to racial and ethnic differences in the provision of mental health care.
The differences between rural and urban communities present another source of diversity in mental health services. People in rural America encounter numerous barriers to the receipt of effective services. Some barriers are geographic, created by the problem of delivering services in less densely populated rural areas and even more sparsely populated frontier areas. Some barriers are cultural, insofar as rural America reflects a range of cultures and life styles that are distinct from urban life. Urban culture and its approach to delivering mental health services dominate mental health services (Beeson et al., 1998).
Rural America is shrinking in size and political influence (Danbom, 1995; Dyer, 1997). As a consequence, rural mental health services do not figure prominently in mental health policy (Ahr & Holcomb, 1985; Kimmel, 1992). Furthermore, rural economies are in decline, and the population is decreasing in most areas (yet expanding rapidly in a few boom areas) (Hannan, 1998). Rural America is no longer a stable or homogeneous environment. The farm crisis of the 1980s unleashed a period of economic hardship and rapid social change, adversely affecting the mental health of the population (Ortega et al., 1994; Hoyt et al., 1995).
Policies and programs designed for urban mental health services often are not appropriate for rural mental health services (Beeson et al., 1998). Beeson and his colleagues (1998) list a host of important differences that should be considered in designing rural mental health services. In an era of specialized services, rural mental health relies heavily on primary medical care and social services. Stigma is particularly intense in rural communities, where anonymity is difficult to maintain (Hoyt et al., 1997). In an era of expanding private mental health services, rural mental health services have been predominantly publicly funded. Consumer and family involvement in advocacy, characteristic of urban and suburban areas, is rare in rural America. The supply of services and providers is limited, so choice is constrained. Mental health services in rural areas cannot achieve certain economies of scale, and some state-of-the art services (e.g., assertive community treatment) are inefficient to deliver unless there is a critical mass of patients. Informal supports and indigenous healers assume more importance in rural mental health care.
Rural mental health concerns are being raised nationally (Rauch, 1997; Ciarlo, 1998; Beeson et al., 1998). Model programs offer new designs for services (Mohatt & Kirwan, 1995), particularly through the integration of mental health and primary care (Bird et al., 1995, 1998; Size, 1998). Newer technology, such as advanced telecommunications in the form of telemental health, may improve rural access to expertise from professionals located in urban areas (Britain, 1996; La Mendola, 1997; Smith & Allison, 1998). Internet access, videoconferencing, and various computer applications offer an opportunity to enhance the quality of care in rural mental health services.