Community Support

Notes from a Roundtable on Conceptualizing and Measuring Cultural Competence

Introduction

Over the last three decades there has been a slow movement in the field of mental health toward improved services for members of minority populations. The questions that have always been in the background for this movement are "What critical components of mental health service need to be changed to make them culturally appropriate for each of the major racial/ethnic populations?" and "Which new services need to be added?"

The creation of the knowledge base needed to answer this critical, complex question was initiated in the early 1970s, when the National Institute of Mental Health (NIMH) established the Minority Mental Health Research Center. The Minority Center developed a project grant program for individual research studies and also funded a "research center" for each of four major racial/ethnic groups: African Americans, Asian Americans, Hispanic Americans, and Native Americans. Each of the four centers established their own research agenda to study the critical needs and issues for their respective groups. Each of the research centers have facilitated planning and education conferences for their stakeholders as the knowledge base has been synthesized.

A second major national milestone in the movement toward culturally competent mental health services came in 1988, when the NIMH Child and Adolescent Service System Program (CASSP) established a Minority Initiative Resource Committee. A subcommittee made its first priority the development of a monograph on culturally competent services. This effort, begun in May 1988, resulted in a monograph entitled Toward A Culturally Competent System of Care (Cross et al., 1989). The monograph was a seminal effort because it provided a definition of cultural competence and established a six-point cultural competence continuum for mental health services provided to minority children and adolescents and their families. A second monograph, entitled Towards A Culturally Competent System of Care: Programs Which Utilize Culturally Competent Principles, was published in December 1991 to "assist states and communities in planning, designing, and implementing culturally competent systems of care" (Issacs and Benjamin, 1991).

The pioneering work within the CASSP minority initiative influenced the development of culturally competent programs for adults with serious mental illness. In April 1993, the first national conference on The Journey of Native American People with Serious Mental Illness was held in Albuquerque, New Mexico, with "tribal, state, and federal representatives and all of the parties really involved in the service system sitting down in the same room together" (Sanchez & McGuirk, 1994). A major goal of the conference was working together to ensure a coordinated, efficient, culturally relevant system of care. A second national conference, titled The Continuing Journey of Native American People with Serious Mental Illness: Building Hope was held in Rapid City, South Dakota, in October 1995, to continue the work initiated in 1993 (Bull Bear & Flaherty, 1997). In 1994, the Community Support Branch of the newly constituted Center for Mental Health Services (CMHS) contracted with the WICHE Mental Health Program to do a cultural competence manual for state mental health authorities (Muñoz & Sanchez, 1996). In 1995, the Strategic Planning Conference on Hispanic Behavioral Health Workforce Development focused on the need for increased cultural competence in state and community mental health systems (Sanchez & Obata, 1986). It was this conference which recommended the development of cultural competence standards for mental health services to Hispanic populations. As a result, with the sponsorship of the WICHE Mental Health Program, a national panel of Hispanic mental health professionals, family members, and consumers was established to develop cultural competence standards for programs serving Hispanic populations.

In 1996, as part of their Managed Care and Work Force Training Initiative, CMHS contracted with the WICHE Mental Health Program to continue working with the Hispanic panel and to establish two new panels to work on standards for Native American/Alaskan Native populations and Asian/Pacific Islander populations. Similarly, a panel to develop standards for African American populations was established separately under the auspices of the University of Pennsylvania. During the standard development process under the leadership of the WICHE Mental Health Program, the four national panels began sharing materials and ideas. After drafting ethnic-specific standards, representatives of the four panels met together in Washington, DC in June 1997, under the sponsorship of CMHS and the WICHE Mental Program, to reach consensus about which core cultural competence standards would be applicable to all four groups. Consensus was achieved and the core standards were presented to CMHS in early 1998 by the WICHE Mental Health Program.

Several states have taken the initiative in implementing cultural competence standards and/or regulations. California has been the most active and progressive by issuing regulations under their Medicaid Mental Health Program, which required that each County Mental Health Authority submit a cultural competence plan by July 1998. The regulations included standards to guide the county plans (California Department of Mental Health, 1997). The plans were submitted and reviewed by committees established by the state. The counties are now in various stages of implementation of their plans.

There has been a three-decade history of concern about the need to develop appropriate mental health systems of care for racial/ethnic populations concluding with the relatively recent development of cultural competence guidelines and standards to facilitate related systems change. CMHS, the Evaluation Center at HSRI, and the WICHE Mental Health Program all recognize a great need to improve the mental health system capacity to evaluate the process of implementation of systems change related to cultural competence. There is also a great need to be able to define and measure the consumer outcomes that result from the systems change and to measure the cost-effectiveness of these changes. Of course, the impact of these changes cannot be evaluated without baseline data collected with valid instruments for assessing the current cultural competence at system, program, and individual clinician levels.

To begin to clarify the issues inherent in these evaluation needs and to develop a strategy for resolving these issues, a roundtable discussion of experts in evaluation methodology and experts in cultural competence was convened last December in Denver, Colorado.

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