Cultural Competence Standards
in Managed Care Mental Health Services:
Four Underserved/Underrepresented
Racial/Ethnic Groups

IV. Provider Competencies

Knowledge, Understanding, Skills, and Attitudes

Standard

Essential components of core continuing education to ensure cultural competence among clinical staff and to promote effective response to the mental health needs of individuals from the four groups include the following areas of knowledge and/or skills: understanding of consumer populations' backgrounds, clinical issues, how to provide appropriate treatment, agency/provider role, communicating effectively across cultures, providing quality assessments, formulating and implementing quality treatment plans, providing quality treatment, using one's self and knowledge in the treatment process, and attitudes.

Consumer Populations' Backgrounds

Continuing education shall include:

1. Factors which define cultural differences between and among different racial/ethnic populations, including differences related to history, traditions, values, belief systems, acculturation and migration patterns, reasons for immigration/migration, and dialect and language fluency;
2. Particular psychosocial stressors and traumas relevant for consumers from the four groups. These include war, trauma, violence, migration, unique aspects of cultural survival and maintenance, socioeconomic status, political unrest, racism, discrimination, and culturally-based belief systems;
3. The effects of the acculturation process on individuals from the four groups; and
4. How class, ethnicity, social status, and racism influence behavior, attitudes, values, belief systems, and mental health of consumers from the four groups.

Clinical Issues

Continuing education shall include:

1. Differences in symptom expression, symptom language, and symptomatic patterns of individuals from the four groups with mental illness/emotional disturbance;
2. Culture-bound syndromes associated with the four groups and their subcultures;
3. Differences in thresholds of psychiatric distress in consumers from the four groups and tolerance of symptomotology by their natural support systems;
4. Nuances of verbal and nonverbal language, speech patterns, and communication styles in the four groups and their subgroups;
5. Dynamics of language use and conceptual frameworks among monolingual and bilingual consumers from the four groups;
6. Differences in the attribution of mental illness (religious, supernatural, etc.) and issues of stigma specific to specific racial/ethnic groups and subgroups;
7. Differences between "culturally acceptable" behaviors and psychopathology within the four groups and their subgroups;
8. Help-seeking behaviors of individuals from the four groups;
9. Role and manifestation of spiritual, tradition, values, and practice beliefs and their integration into treatment;
10. Consumers from the four groups within a family life cycle and intergenerational conceptual framework in addition to individual identity development framework;
11. The varying effects of commonly used medications on individuals from the four groups;
12. Assessment tools and their limitations, particularly their uses and limitations for the four groups; and
13. The impact of psychosocial stressors versus intrapsychic stressors in consumers from the four groups.

How to Provide Appropriate Treatment

Continuing education shall include:

1. Differences in the acceptability and effectiveness of various treatment modalities for individuals from the four groups;
2. Use of culturally informed and qualified interpreters for monolingual consumers when qualified bilingual clinicians are not available;.
3. Use of culturally informed individuals, including family members when appropriate, by clinicians serving consumers from the four groups;
4. Social, political, and economic conditions in the community when developing, implementing, and evaluating programs for consumers and families from the four groups;
5. Use of natural community supports and other community resources for consumers from the four groups; and
6. Indigenous healing practices and the role of belief systems (religion and spirituality) in the treatment of consumers from the four underserved/ underrepresented groups.

Agency/ProviderRole

Continuing education shall include:

1. Personal and cultural biases of staff and how they may affect benefits and service design and delivery;
2. The role and types of power relationships within the community, agency, or institution and their effect on consumers from the four groups;
3. Ways that mainstream professional values may conflict with, or be responsible to, the needs of consumers from the four groups;
4. Effects of institutional racism and historical barriers on social service policies for individuals from the four groups, and knowledge of how to reduce barriers through use of and participation in systems change efforts; and
5. Resources (agencies, persons, informal helping networks, research) that shall be utilized on behalf of consumers from the four groups and their communities.

Communicating Effectively Across Cultures

Continuing education shall include:

1. Communicating and listening effectively across cultures, and across all levels of care; and
2. Engaging and establishing rapport with individuals from the four groups using socially and culturally appropriate conventions.

Providing Quality Assessments

Continuing education shall include:

1. Conducting culturally competent interviews which take into account the psychological, social, biological, physiological, cultural, political, spiritual, and environmental aspects of the consumer's experience;
2. Assessing consumers with an understanding of cultural differences in symptom expression, thresholds of psychiatric distress, and culture-bound syndromes; and
3. Appropriately referring for assessment and using assessment tools, recognizing the limitations of psychological tests and testing procedures when used with consumers from the four groups.

Formulating and Implementing Quality Care and Treatment Plans

Continuing education shall include:

1. Formulating culturally competent service plans (case management and treatment) that fit consumer and family's concept of mental illness;
2. Creating and implementing multidimensional service plans (case management and treatment) that include culture, family, and community;
3. Utilizing culturally appropriate community resources (e.g., family, clans, societies, church, community members, and other groups); and
4. Providing psychotherapeutic and psychopharmacological interventions with an understanding of different biological and physiological responses to medications based on physical, cultural, and racial/ethnic differences.

Providing Quality Treatment

Continuing education shall include:

1. Providing psycho-educational interventions which promote consumer and family voice and ownership in shaping the service delivery system;
2. Empowering and advocating for consumers, families, and communities;
3. Using consumer's preferred language and dialect to elicit the range and nuances of emotions, feelings, dynamics, etc.;
4. Referring to providers who use consumer's preferred language/dialect;
5. Knowing when and how to use trained interpreters; and
6. When indicated, appropriately addressing racial/ethnic issues in treatment.

Using One's Self and Knowledge in the Treatment Process

Continuing education shall include:

1. Recognizing one's own limitations, and knowing when to refer consumers to consultants from the four groups; and
2. Evaluating applications of new techniques, exemplary practices, research, and knowledge as to their validity and applicability in working with the four groups.

Attitudes

Continuing education shall include:

1. Demonstrating attitudes that indicate a respect for the consumer's immigration, migration, colonization, and acculturation experiences;
2. Demonstrating attitudes that indicate a respect for the diverse heritages, cultures, and experiences of consumers from the four groups;
3. Demonstrating attitudes that indicate a willingness to work with culturally, ethnically, and racially diverse populations; and
4. Demonstrating an understanding of and respect for how, as provider/therapist, one's self (especially the degree of one's cultural, ethnic, and racial match to the consumer) may influence the therapeutic relationship; and recognizing the need to process this dynamic, and in some cases refer the consumer for his/her treatment benefit.

Recommended Performance Indicators

1. Ongoing program planning and implementation of behavioral health services which meet the needs of consumers from the four groups and their communities.
2. Human Resource Development Plan inclusive of recruitment, retention and development of staff at all levels to enhance and ensure quality culturally competent services to consumers from the four groups and their communities.

Recommended Outcomes

1. Provider shall demonstrate ongoing assessment of behavioral health needs of consumers from the four groups and their communities.
   Benchmark: Documented annual assessment and service planning process.
2. Provider services and programs that reflect the needs of consumers from the four racial/ ethnic groups and their communities.
   Benchmark: Implementation of services and programs which are commensurate with the (changing) needs of the consumer and community using consumer and community assessment data..
3. Human Resource Development Plan to enhance culturally competent mental health services for the four racial/ethnic groups is established and implemented.
   Benchmark: Documented participation of all provider staff in annual training sessions.

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SMA00-3457
1/2001