Evidence-Based Practices: Shaping Mental Health Services Toward Recovery

Assertive Community Treatment

Statement on Cultural Competence

Cultural competence is about adapting mental health care to meet the needs of consumers from diverse cultures. One key aim is to improve their access to care. Others are to build trust and to promote their engagement and retention in care.

Above all, cultural competence aims to improve the quality of care and to help consumers recover quicker and better. Its broader societal purpose is to reduce or eliminate mental health disparities affecting disenfranchised groups.

This statement on cultural competence lays out ways for programs to tailor their evidence-based practices to the cultures they serve. It is meant as a guide, rather than a set of fidelity measures. The statement begins with the basics: what is culture, how does it affect care, what is cultural competence, and why is it important. It then gives examples of how cultural competence is translated into practice.

What is culture, and how does it affect care?

A culture is broadly defined as a common heritage or set of beliefs, norms, and values shared by a group of people. People who are placed, either by census categories, or through self-identification, into the same racial or ethnic group are often assumed to share the same culture; however, not all members grouped together in a given category will share the same culture. There is great diversity within each of these broad categories and individuals may identify with a given racial or ethnic culture to varying degrees. Others may identify with multiple cultures, including those associated with their religion, profession, sexual orientation, region, or disability status.

Culture is dynamic. It changes continually and is influenced both by people’s beliefs and the demands of their environment. Immigrants from different parts of the world arrive in the United States with their own culture but gradually begin to adapt and develop new, hybrid cultures that allow them to function within the dominant culture. This process is referred to as acculturation. Even groups that have been in the United States for many generations may share beliefs and practices that maintain influences from multiple cultures. This complexity necessitates an individualized approach to understanding culture and cultural identity in the context of mental health services.

The culture someone comes from influences many aspects of care, starting with whether the person thinks care is needed or not. Culture influences what concerns that person brings to the clinical setting, what language is used to express those concerns, and what coping styles are adopted. Culture affects family structure, living arrangements, and how much support someone receives in time of difficulties.

Culture also influences patterns of help-seeking?whether someone starts with a primary care doctor, a mental health program, or goes to a minister, spiritual advisor, or community elder. Finally, culture affects how much stigma someone attaches to mental health problems, and how much trust is placed in the hands of providers.

It’s easy to think of culture as only belonging to consumers without realizing how it also applies to providers and administrators. Their professional culture influences how they organize and deliver care. Some cultural influences are more obvious than others, like the manner in which clinicians ask questions or interact with consumers. Less obvious but equally important are what hours a clinic has, the importance the staff attaches to reaching out to family members and community leaders, and the respect they accord to the culture of each consumer entering their doors.

Knowing how culture influences so many aspects of mental health care underscores the importance of adapting programs to respond to, and be respectful of, the diversity of the surrounding community.

Why cultural competence?

For decades, many mental health programs neglected the growing diversity around them. Often, people from non-majority cultures found programs off-putting and hard to access. They avoided getting care, stopped looking for care, or, if they managed to find care, they dropped out. The result was troubling disparities: many minority groups faced lower access to care, lower use of care, and poorer quality of care. Altogether, those disparities translated into millions of people suffering needless disability from mental illness.

Disparities are most apparent for racial and ethnic minority groups such as African Americans, American Indians and Alaska Natives, Asian Americans, Hispanic Americans, and Native Hawaiians and other Pacific Islanders. But disparities also affect many other groups, such as women and men, children and older adults, people from rural areas, and people with different sexual orientations, or with physical or developmental disabilities.

Starting in the late 1980’s, the mental health profession responded with a new approach to care called “cultural competence.” Cultural competence was originally defined as a set of congruent behaviors, attitudes, and policies that come together in a system, agency, or among professionals and enables that system, agency, or those professionals to work effectively in cross–cultural situations.

What is cultural competence?

Cultural competence is an approach to delivering mental health services grounded in the assumption that services are more effective when they are provided within the most relevant and meaningful cultural, gender-sensitive, and age-appropriate context for the people being served. The Surgeon General defined cultural competence in the most general terms as “the delivery of services responsive to the cultural concerns of racial and ethnic minority groups, including their languages, histories, traditions, beliefs, and values." In most cases, the term cultural competence refers to sets of guiding principles, developed to increase the ability of mental health providers, agencies, or systems to meet the needs of diverse communities, including racial and ethnic minorities.

While consumers, families, providers, policymakers, and administrators have long acknowledged the intrinsic value of cultural competence, insufficient research has been dedicated to identifying its key ingredients. Therefore, the field still struggles to define, operationalize, and measure cultural competence.

The word “competence” is somewhat misleading. Competence usually implies a set of criteria on which to evaluate a program. But this is not yet true for cultural competence, which is still under-researched. The term “competence,” in this context, means that the responsibility to tailor care to different cultural groups belongs to the system, not to the consumer. Every provider or administrator involved in delivering care?from mental health authorities down to clinical supervisors and practitioners?bears responsibility for trying to make their programs accessible, appropriate, appealing, and effective for the diverse communities that they serve. Many do it naturally.

How is cultural competence related to evidence-based practices?

Evidence-based practices are for every consumer who enters care, regardless of what culture they come from, according to the Surgeon General.1 But programs often need to make adjustments to evidence-based practices in order to make them accessible and effective for cultural groups that differ in language or behavior from the original study populations. The adjustments should facilitate, rather than interfere with, a program’s ability to implement evidence-based practices using the fidelity measures in this toolkit.

In a nutshell, to deliver culturally competent evidence-based practices means tailoring either the practice itself or the context in which the practice is delivered to the unique communities served by a mental health program.

In time, there may be specific fidelity measures used to assess a program’s cultural competence. But this is not the case now. The concept of cultural competence is too new and the evidence base is too small. While the evidence is being collected, programs can and should take the initiative to tailor evidence-based practices to each of the cultural groups they serve, like translating their information brochures into the languages often used in their communities. Others steps are featured in the next section.

Many providers ask, how can we know if evidence-based practices apply to a particular ethnic, racial, or cultural group if the research supporting those practices was done on a very different population? The answer is that we will not know for sure until we try; but the limited research that does exist, suggests that evidence-based practices, with minor modifications or not, work well across cultures. Furthermore, because evidence-based practices represent the highest quality of care currently available, it is a matter of fairness and prudence to provide them to all people who may need them. Yet the question remains, how can we do this effectively?

1 U.S. Department of Health and Human Services. (2001). Mental health: culture, race, and ethnicity. A report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health.

How can cultural competence be put into practice?

All programs are encouraged to be more culturally competent, even though research has not yet generated a set of evidence-based practices to achieve cultural competence.

A variety of straightforward steps can be taken to make programs more responsive to the people they serve. The steps might apply to all facets of a program and need not be restricted to the evidence-based practice covered by this toolkit. The following steps are meant to be illustrative, not prescriptive:

Understand the racial, ethnic, and cultural demographics of the population served
Become most familiar with one or two of the groups most commonly encountered
Create a cultural competence advisory committee consisting of consumers, family and community organizations
Translate your forms and brochures
Offer to match a consumer with a practitioner of a similar background
Have access to trained mental health interpreters
Ask each client about their cultural background and identity
Incorporate cultural awareness into the assessment and treatment of each consumer
Tap into natural networks of support, such as the extended family and community groups representing the culture of a consumer
Reach out to religious and spiritual organizations to encourage referrals or as another network of support
Offer training to staff in culturally responsive communication or interviewing skills.
Understand that some behaviors considered in one culture to be signs of psychopathology are acceptable in a different culture
Be aware that a consumer from another culture may hold different beliefs about causes and treatment of illness

Cultural competence is also important for planners and for mental health authorities. Here are a few examples of the ways a public mental health authority or program administrators can become more culturally competent.

Designate someone with part-time or full-time responsibility for improving and monitoring cultural competence
Create a strategic plan to incorporate cultural competence into programs throughout a system
Establish an advisory committee that includes representatives of all the major racial, ethnic, and cultural groups being served
Address barriers to care (cultural, linguistic, geographic or economic)
Provide staffing that reflects the composition of the community being served
Conduct regular organizational self-assessments of cultural competence
Collect and analyze data to examine disparities in services
Designate specific resources for cultural competence training
Include cultural competence in quality assurance and quality improvement activities and projects

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