Cultural Competence and Diversity

Cultural Competence Model

Flores (2000) proposed a five component model for cultural competency to help providers work with patients from any cultural group. These five components include:

• Normative cultural values - The provider needs to be familiar with the cultural values of his/her patients because these values may affect the health of the patient. Familiarity with the culture can be accomplished through literature concerning the ethnic group and consultations with members of the community.
• Language issues - Interpreters are essential when the patient is not fluent in English and the provider/staff is not fluent in the patient's language.
• Folk illnesses - Learn about common folk practices/illnesses of different cultures, however do not assume that the patient adheres to these beliefs. Communication is important so it is vital to ask the patient about beliefs he/she may have and about any current treatments the/she may be receiving.
• Patient/ parent beliefs - Identify patient beliefs and recommend alternatives to any treatments that may be harmful. Integration of harmless remedies associated with a person's culture/belief should be considered.
• Provider practices - Providers need to take note of any ethnic disparities that may arise in clinical procedures and health outcomes. Regular monitoring is essential.

This cultural competence model contains similar elements that were listed in the recommendations provided by the health professionals/administrators that participated in the study. Thus, many of the cultural issues found in a provider's general practice may be similar to those issues present for children and adolescents in a school-based health center. Hopefully, through taking these points into consideration, school-based health centers can provide care that is welcoming to all of its students, thereby maximizing the benefits for these children and adolescents.

Cultural Competence Model

Flores (2000) proposed a five component model for cultural competency to help providers work with patients from any cultural group. These five components include:

• Normative cultural values - The provider needs to be familiar with the cultural values of his/her patients because these values may affect the health of the patient. Familiarity with the culture can be accomplished through literature concerning the ethnic group and consultations with members of the community.
• Language issues - Interpreters are essential when the patient is not fluent in English and the provider/staff is not fluent in the patient's language.
• Folk illnesses - Learn about common folk practices/illnesses of different cultures, however do not assume that the patient adheres to these beliefs. Communication is important so it is vital to ask the patient about beliefs he/she may have and about any current treatments the/she may be receiving.
• Patient/ parent beliefs - Identify patient beliefs and recommend alternatives to any treatments that may be harmful. Integration of harmless remedies associated with a person's culture/belief should be considered.
• Provider practices - Providers need to take note of any ethnic disparities that may arise in clinical procedures and health outcomes. Regular monitoring is essential.

This cultural competence model contains similar elements that were listed in the recommendations provided by the health professionals/administrators that participated in the study. Thus, many of the cultural issues found in a provider's general practice may be similar to those issues present for children and adolescents in a school-based health center. Hopefully, through taking these points into consideration, school-based health centers can provide care that is welcoming to all of its students, thereby maximizing the benefits for these children and adolescents.

Mental Illness and Minorities
Minorities Have Trouble Getting Help

Although minorities are just a likely as non-minorities to experience severe mental disorders such as anxiety, depression, bipolar disorder and schizophrenia, they are far less likely to receive treatment. For instance, the percentage of African Americans receiving needed care is only half that of whites, and 24% of Hispanics with depression and anxiety receive appropriate care compared to 34% of whites with the same diagnosis. Reasons include a lack of access to services, cultural and language barriers, and limited research concerning mental health and minorities.

Many studies have found that lack of access to services is strongly associated with one's level of income and access to medical insurance. Racial and ethnic minorities have higher rates of poverty and a much greater likelihood of being uninsured. For instance, 8% of whites live below the poverty level compared to 22% of African Americans and 27% of Mexican and Native Americans. The percentage of uninsured minorities is over half that of whites.

Individuals experiencing symptoms of a mental disorder are most likely to seek help from their primary care physician, but close to 30% of Hispanics and 20% of African Americans do not have a usual source of healthcare. Even when minorities seek care from a primary care physician, they are less likely to receive appropriate treatment. Also, many minorities live in rural, isolated areas where access to mental health services is limited.

Language is a significant barrier to receiving appropriate mental healthcare. Diagnosis and treatment of mental disorders greatly depends on the ability of the patient to explain their symptoms to their physician and understand steps for treatment. The language barrier often deters individuals from seeking treatment. Thirty five percent of Asian Americans and Pacific Islanders (AA/PIs) live in households where the primary language is not English and 40% of Hispanics living in the U.S. do not speak English.

Culture, a system of shared meanings, is defined as a common heritage or set of beliefs, expectations for behavior, and values. Culture significantly influences the definition and treatment of mental illness, affecting the way individuals describe their symptoms and the symptoms they exhibit. For instance, African Americans experience symptoms uncommon among other groups such as isolated sleep paralysis, or the inability to move while falling asleep or waking up. Some Hispanics experience symptoms of anxiety that include uncontrollable screaming, crying, trembling, and seizure like fainting. Cultural beliefs about mental health strongly affect whether or not some people seek treatment, a person's coping styles and social supports, and the stigma they attach to mental illness.

Many people from different cultures see mental illness as shameful and delay treatment until symptoms reach crisis proportions. The culture of physicians and mental health professionals influences how they interpret symptoms and interact with patients.

Research to evaluate different minority groups' response to treatment is limited. Very few studies exist that investigate the appropriateness of certain types of treatment. For example, some research suggests that African Americans metabolize psychiatric medications more slowly than whites, but often receive higher dosages than do whites, leading to more severe side effects. More extensive research is needed to insure minorities receive appropriate treatment. Finally, while all groups experience mental disorders, minorities are over represented in populations at high risk for experiencing mental illness, including people who are exposed to violence, homeless, in prison or jail, foster care, or the child welfare system. At risk populations are far less likely to receive services than the general population.

Culture Counts: The Influence of Culture and Society on Mental Health, Mental Illness

Introduction

To better understand what happens inside the clinical setting, this section looks outside. It reveals the diverse effects of culture and society on mental health, mental illness, and mental health services. This understanding is key to developing mental health services that are more responsive to the cultural and social contexts of racial and ethnic minorities.

With a seemingly endless range of subgroups and individual variations, culture is important because it bears upon what all people bring to the clinical setting. It can account for minor variations in how people communicate their symptoms and which ones they report. Some aspects of culture may also underlie culture bound syndromes: sets of symptoms much more common in some societies than in others. More often, culture bears on whether people even seek help in the first place, what types of help they seek, what types of coping styles and social supports they have, and how much stigma they attach to mental illness. Culture also influences the meanings that people impart to their illness. Consumers of mental health services, whose cultures vary both between and within groups, naturally carry this diversity directly to the service setting.
The cultures of the clinician and the service system also factor into the clinical equation. Those cultures most visibly shape the interaction with the mental health consumer through diagnosis, treatment, and organization and financing of services. It is all too easy to lose sight of the importance of culture - until one leaves the country. Travelers from the United States, while visiting some distant frontier, may find themselves stranded in miscommunications and seemingly unorthodox treatments if they seek care for a sudden deterioration in their mental health.

Health and mental health care in the United States are embedded in Western science and medicine, which emphasize scientific inquiry and objective evidence. The self correcting features of modern science - new methods, peer review, and openness to scrutiny through publication in professional journals - ensure that as knowledge is developed, it builds on, refines, and often replaces older theories and discoveries. The achievements of Western medicine have become the cornerstone of health care worldwide.

What follows are numerous examples of the ways in which culture influences mental health, mental illness, and mental health services. This section is meant to be illustrative, not exhaustive. It looks at the culture of the patient, the culture of the clinician, and the specialty in which the clinician works. With respect to the context of mental health services, this section deals with the organization, delivery, and financing of services, as well as with broader social issues - racism, discrimination, and poverty - which affect mental health.

Culture refers to a groups shared set of beliefs, norms, and values. Because common social groupings (e.g., people who share a religion, youth who participate in the same sport, or adults trained in the same profession) have their own cultures, this section has separate sections on the culture of the patient as well as the culture of the clinician. Where cultural influences end and larger societal influences begin, there are contours not easily demarcated by social scientists. This section takes a broad view about the importance of both culture and society, yet recognizes that they overlap in ways that are difficult to disentangle through research.

What becomes clear is that culture and social contexts, while not the only determinants, shape the mental health of minorities and alter the types of mental health services they use. Cultural misunderstandings between patient and clinician, clinician bias, and the fragmentation of mental health services deter minorities from accessing and utilizing care and prevent them from receiving appropriate care.

Culture of the Patient

The culture of the patient, also known as the consumer of mental health services, influences many aspects of mental health, mental illness, and patterns of health care utilization. One important cautionary note, however, is that general statements about cultural characteristics of a given group may invite stereotyping of individuals based on their appearance or affiliation. Because there is usually more diversity within a population than there is between populations (e.g., in terms of level of acculturation, age, income, health status, and social class), information in the following sections should not be treated as stereotypes to be broadly applied to any individual member of a racial, ethnic, or cultural group.

Symptoms, Presentation, and Meaning

The symptoms of mental disorders are found worldwide. They cluster into discrete disorders that are real and disabling (U.S. Department of Health and Human Services [DHHS], 1999). Mental disorders are defined in the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association [APA], 1994). Schizophrenia, bipolar disorder, panic disorder, obsessive compulsive disorder, depression, and other disorders have similar and recognizable symptoms throughout the world (Weissman et al., 1994, 1996, 1997, 1998). Culture bound syndromes, which appear to be distinctive to certain ethnic groups, are the exception to this general statement. Research has not yet determined whether culture bound syndromes are distinct from established mental disorders, are variants of them, or whether both mental disorders and culture bound syndromes reflect different ways in which the cultural and social environment interacts with genes to shape illness.

One way in which culture affects mental illness is through how patients describe (or present) their symptoms to their clinicians. There are some well recognized differences in symptom presentation across cultures. Asian patients, for example, are more likely to report their somatic symptoms, such as dizziness, while not reporting their emotional symptoms. Yet, when questioned further, they do acknowledge having emotional symptoms (Lin & Cheung, 1999). This finding supports the view that patients in different cultures tend to selectively express or present symptoms in culturally acceptable ways (Kleinman, 1977, 1988).

Cultures also vary with respect to the meaning they impart to illness, their way of making sense of the subjective experience of illness and distress (Kleinman, 1988). The meaning of an illness refers to deep seated attitudes and beliefs a culture holds about whether an illness is "real" or "imagined," whether it is of the body or the mind (or both), whether it warrants sympathy, how much stigma surrounds it, what might cause it, and what type of person might succumb to it. Cultural meanings of illness have real consequences in terms of whether people are motivated to seek treatment, how they cope with their symptoms, how supportive their families and communities are, where they seek help (mental health specialist, primary care provider, clergy, and/or traditional healer), the pathways they take to get services, and how well they fare in treatment. The consequences can be grave extreme distress, disability, and possibly, suicide when people with severe mental illness do not receive appropriate treatment.

Causation and Prevalence

Cultural and social factors contribute to the causation of mental illness, yet that contribution varies by disorder. Mental illness is considered the product of a complex interaction among biological, psychological, social, and cultural factors. The role of any one of these major factors can be stronger or weaker depending on the disorder (DHHS, 1999).

The prevalence of schizophrenia, for example, is similar throughout the world (about 1 percent of the population), according to the International Pilot Study on Schizophrenia, which examined over 1,300 people in 10 countries (World Health Organization [WHO], 1973). International studies using similarly rigorous research methodology have extended the WHO's findings to two other disorders: The lifetime prevalence of bipolar disorder (0.3-1.5%) and panic disorder (0.4-2.9%) were shown to be relatively consistent across parts of Asia, Europe, and North America (Weissman et al., 1994, 1996, 1997, 1998). The global consistency in symptoms and prevalence of these disorders, combined with results of family and molecular genetic studies, indicates that they have high heritability (genetic contribution to the variation of a disease in a population) (National Institute of Mental Health [NIMH], 1998). In other words, it seems that culture and societal factors play a more sub-ordinate role in causation of these disorders.

Cultural and social context weigh more heavily in causation of depression. In the same international studies cited above, prevalence rates for major depression varied from 2 to 19 percent across countries (Weissman et al., 1996). Family and molecular biology studies also indicate less heritability for major depression than for bipolar disorder and schizophrenia (NIMH, 1998). Taken together, the evidence points to social and cultural factors, including exposure to poverty and violence, playing a greater role in the onset of major depression. In this context, it is important to note that poverty, violence, and other stressful social environments are not unique to any part of the globe, nor are the symptoms and manifestations they produce. However, factors often linked to race or ethnicity, such as socioeconomic status or country of origin can increase the likelihood of exposure to these types of stressors.

Cultural and social factors have the most direct role in the causation of post-traumatic stress disorder (PTSD). PTSD is a mental disorder caused by exposure to severe trauma, such as genocide, war combat, torture, or the extreme threat of death or serious injury (APA, 1994). These traumatic experiences are associated with the later development of a longstanding pattern of symptoms accompanied by biological changes (Yehuda, 2000). Traumatic experiences are particularly common for certain populations, such as U.S. combat veterans, inner-city residents, and immigrants from countries in turmoil. Asian Americans and Hispanic Americans reveal alarming rates of PTSD in communities with a high degree of pre-immigration exposure to trauma. For example, in some samples, up to 70 percent of refugees from Vietnam, Cambodia, and Laos met diagnostic criteria for PTSD. By contrast, studies of the U.S. population as a whole find PTSD to have a prevalence of about 4 percent (DHHS, 1999).

Suicide rates vary greatly across countries, as well as across U.S. ethnic sub-groups (Moscicki, 1995). Suicide rates among males in the United States are highest for American Indians and Alaska Natives (Kachur et al., 1995). Rates are lowest for African American women (Kachur et al., 1995). The reasons for the wide divergence in rates are not well understood, but they are likely influenced by variations in the social and cultural contexts for each subgroup (van Heeringen et al., 2000; Ji et al., 2001).

Even though there are similarities and differences in the distribution of certain mental disorders across populations, the United States has an aggregate rate of about 20 percent of adults and children with diagnosable mental disorders (DHHS, 1999; Table 1-1). This aggregate rate for the population as a whole does not have sufficient representation from most minority groups to permit comparisons between whites and other ethnic groups. The rates of mental disorder are not sufficiently studied in many smaller ethnic groups to permit firm conclusions about overall prevalence; however, several epidemiological studies of ethnic populations, supported by the NIMH, are currently in progress.

Family Factors

Many features of family life have a bearing on mental health and mental illness. Starting with etiology family factors can protect against, or contribute to, the risk of developing a mental illness. For example, supportive families and good sibling relationships can protect against the onset of mental illness. On the other hand, a family environment marked by severe marital discord, overcrowding, and social disadvantage can contribute to the onset of mental illness. Conditions such as child abuse, neglect, and sexual abuse also place children at risk for mental disorders and suicide (Brown et al., 1999; Dinwiddie et al., 2000).

Family risk and protective factors for mental illness vary across ethnic groups. But research has not yet reached the point of identifying whether the variation across ethnic groups is a result of that group's culture, its social class and relationship to the broader society, or individual features of family members.

One of the most developed lines of research on family factors and mental illness deals with relapse in schizophrenia. The first studies, conducted in Great Britain, found that people with schizophrenia who returned from hospitalizations to live with family members who expressed criticism, hostility, or emotional involvement (called high expressed emotion) were more likely to relapse than were those who returned to family members who expressed lower levels of negative emotion (Leff & Vaughn, 1985; Kavanaugh, 1992; Bebbington & Kuipers, 1994; Lopez & Guarnaccia, 2000). Later studies extended this line of research to Mexican American samples. These studies reconceptualized the role of family as a dynamic interaction between patients and their families, rather than as static family characteristics (Jenkins, Kleinman, & Good, 1991; Jenkins, 1993). Using this approach, a study comparing Mexican American and white families found that different types of interactions predicted relapse. For the Mexican American families, interactions featuring distance or lack of warmth predicted relapse for the individual with schizophrenia better than interactions featuring criticism. For whites, the converse was true (Lopez et al., 1998). This example, while not necessarily generalizable to other Hispanic groups, suggests avenues by which other culturally based family differences may be related to the course of mental illness.

Coping Styles

Culture relates to how people cope with everyday problems and more extreme types of adversity. Some Asian American groups, for example, tend not to dwell on upsetting thoughts, thinking that reticence or avoidance is better than outward expression. They place a higher emphasis on suppression of affect (Hsu, 1971; Kleinman, 1977), with some tending first to rely on themselves to cope with distress (Narikiyo & Kameoka, 1992). African Americans tend to take an active approach in facing personal problems, rather than avoiding them (Broman, 1996). They are more inclined than whites to depend on handling distress on their own (Sussman et al., 1987). They also appear to rely more on spirituality to help them cope with adversity and symptoms of mental illness (Broman, 1996; Cooper-Patrick et al., 1997; Neighbors et al., 1998).

Few doubt the importance of culture in fostering different ways of coping, but research is sparse. One of the few, yet well developed lines of research on coping styles comes from comparisons of children living in Thailand versus America. Thailand's largely Buddhist religion and culture encourage self control, emotional restraint, and social inhibition. In a recent study, Thai children were two times more likely than American children to report reliance on covert coping methods such as "not talking back," than on overt coping methods such as "screaming" and "running away" (McCarty et al., 1999). Other studies by these investigators established that different coping styles are associated with different types and degrees of problem behaviors in children (Weisz et al., 1997).

The studies noted here suggest that better understanding of coping styles among racial and ethnic minorities has implications for the promotion of mental health, the prevention of mental illness, and the nature and severity of mental health problems.

Treatment Seeking

It is well documented that racial and ethnic minorities in the United States are less likely than whites to seek mental health treatment, which largely accounts for their under representation in most mental health services (Sussman et al., 1987; Kessler et al., 1996; Vega et al. 1998; Zhang et al., 1998). Treatment seeking denotes the pathways taken to reach treatment and the types of treatments sought (Rogler & Cortes, 1993). The pathways are the sequence of contacts and their duration once someone (or their family) recognizes their distress as a health problem.

Research indicates that some minority groups are more likely than whites to delay seeking treatment until symptoms are more severe. Further, racial and ethnic minorities are less inclined than whites to seek treatment from mental health specialists (Gallo et al., 1995; Chun et al., 1996; Zhang et al., 1998). Instead, studies indicate that minorities turn more often to primary care (Cooper-Patrick et al., 1999a; see later section on Primary Care). They also turn to informal sources of care such as clergy, traditional healers, and family and friends (Neighbors & Jackson, 1984; Peifer et al., 2000). In particular, American Indians and Alaska Natives often rely on traditional healers, who frequently work side by side with formal providers in tribal mental health programs. African Americans often rely on ministers, who may play various mental health roles as counselor, diagnostician, or referral agent (Levin, 1986). The extent to which minority groups rely on informal sources in lieu of, or in addition to, formal mental health services in primary or specialty care is not well studied.

When they use mental health services, Some African Americans prefer therapists of the same race or ethnicity. This preference has encouraged the development of ethnic-specific programs that match patients to therapists of the same culture or ethnicity (Sue, 1998). Many African Americans also prefer counseling to drug therapy (Dwight-Johnson et al., 2000). Their concerns revolve around side effects, effectiveness, and addiction potential of medications (Cooper-Patrick et al., 1997).

The fundamental question raised by this line of research is: Why are many racial and ethnic minorities less inclined than whites to seek mental health treatment? Certainly, the constellation of barriers deterring whites also operates to various degrees for minorities - cost, fragmentation of services, and the societal stigma on mental illness (DHHS, 1999). But there are extra barriers deterring racial and ethnic minorities such as mistrust and limited English proficiency.

Mistrust

Mistrust was identified as a major barrier to the receipt of mental health treatment by racial and ethnic minorities (DHHS, 1999). Mistrust is widely accepted as pervasive among minorities, yet there is surprisingly little empirical research to document it (Cooper-Patrick et al., 1999). One of the few studies on this topic looked at African Americans and whites surveyed in the early 1980s in a national study known as the Epidemiologic Catchment Area (ECA) study. This study found that African Americans with major depression were more likely to cite their fears of hospitalization and of treatment as reasons for not seeking mental health treatment. For instance, almost half of African Americans, as opposed to 20 percent of whites, reported being afraid of mental health treatment (Sussman et al., 1987).

What are the reasons behind the lack of trust? Mistrust of clinicians by minorities arises, in the broadest sense, from historical persecution and from present day struggles with racism and discrimination. It also arises from documented abuses and perceived mistreatment, both in the past and more recently, by medical and mental health professionals (Neal-Barnett & Smith, 1997). A recent survey conducted for the Kaiser Family Foundation (Brown et al., 1999) found that 12 percent of African Americans and 15 percent of Latinos, in comparison with 1 percent of whites, felt that a doctor or health provider judged them unfairly or treated them with disrespect because of their race or ethnic background. Even stronger ethnic differences were reported in the Commonwealth Fund Minority Health Survey: It found that 43 percent of African Americans and 28 percent of Latinos, in comparison with 5 percent of whites, felt that a health care provider treated them badly because of their race or ethnic background (LaVeist et al., 2000). Mistrust of mental health professionals is exploited by present day antipsychiatry groups that target the African American community with incendiary material about purported abuses and mistreatment (Bell, 1996).

Mistrustful attitudes also may be commonplace among other groups. While insufficiently studied, mistrust toward health care providers can be inferred from a group's attitudes toward government operated institutions. Immigrants and refugees from many regions of the world, including Central and South America and Southeast Asia, feel extreme mistrust of government, based on atrocities committed in their country of origin and on fear of deportation by U.S. authorities. Similarly, many American Indians and Alaska Natives are mistrustful of health care institutions; this dates back through centuries of legalized discrimination and segregation.

Stigma

Stigma was portrayed by the SGR as the "most formidable obstacle to future progress in the arena of mental illness and health" (DHHS, 1999). It refers to a cluster of negative attitudes and beliefs that motivate the general public to fear, reject, avoid, and discriminate against people with mental illness (Corrigan & Penn, 1999).

Stigma is widespread in the United States and other Western nations (Bhugra, 1989; Brockington et al., 1993) and in Asian nations (Ng, 1997). In response to societal stigma, people with mental problems internalize public attitudes and become so embarrassed or ashamed that they often conceal symptoms and fail to seek treatment (Sussman et al., 1987; Wahl, 1999). Stigma also lowers their access to resources and opportunities, such as housing and employment, and leads to diminished self esteem and greater isolation and hopelessness (Penn & Martin, 1998; Corrigan & Penn, 1999). Stigma can also be against family members; this damages the consumer's self esteem and family relationships (Wahl & Harman, 1989). In some Asian cultures, stigma is so extreme that mental illness is thought to reflect poorly on family lineage and thereby diminishes marriage and economic prospects for other family members as well (Sue & Morishima, 1982; Ng, 1997).

Stigma is such a major problem that the very topic itself poses a challenge to research. Researchers have to contend with people's reluctance to disclose attitudes often deemed socially unacceptable. How stigma varies by culture can be studied from two perspectives. One perspective is that of the targets of stigma, i.e., the people with symptoms: If they are members of a racial or ethnic minority, are they more likely than whites to experience stigma? The other perspective is that of the public in their attitudes toward people with mental illness: Are members of each racial or ethnic minority group more likely than whites to hold stigmatizing attitudes toward mental illness? The answers to these cross cultural questions are far from definitive, but there are some interesting clues from research.

Turning first to those who experience symptoms, one of the few cross cultural studies questioned Asian Americans living in Los Angeles. The findings were eye opening: Only 12 percent of Asians would mention their mental health problems to a friend or relative (versus 25 percent of whites). A meager 4 percent of Asians would seek help from a psychiatrist or specialist (versus 26 percent of whites). And only 3 percent of Asians would seek help from a physician (versus 13 percent of whites). The study concluded that stigma was pervasive and pronounced for Asian Americans in Los Angeles (Zhang et al., 1998).

Turning to the question of public attitudes toward mental illness, the largest and most detailed study of stigma in the United States was performed in 1996 as part of the General Social Survey, a respected, nationally representative survey being conducted by the National Opinion Research Center since the 1970s. In this study, a representative sample was asked in personal interviews to respond to different vignettes depicting people with mental illness. The respondents generally viewed people with mental illness as dangerous and less competent to handle their own affairs, with their harshest judgments reserved for people with schizophrenia and substance use disorders. Interestingly, neither the ethnicity of the respondent, nor the ethnicity of the person portrayed in the vignette, seemed to influence the degree of stigma (Pescosolido et al., 1999).

By contrast, another large, nationally representative study found a different relationship between race, ethnicity, and attitudes towards patients with mental illness. Asian and Hispanic Americans saw them as more dangerous than did whites. Although having contact with individuals with mental illness helped to reduce stigma for whites, it did not for African Americans. American Indians, on the other hand, held attitudes similar to whites (Whaley, 1997).

Taken together, these results suggest that minorities hold similar, and in some cases stronger, stigmatizing attitudes toward mental illness than do whites. Societal stigma keeps minorities from seeking needed mental health care, much as it does for whites. Stigma is so potent that it not only affects the self esteem of people with mental illness, but also that of family members. The bottom line is that stigma does deter major segments of the population, majority and minority alike, from seeking help. It bears repeating that a majority of all people with diagnosable mental disorders do not get treatment (DHHS, 1999).

Immigration

Migration, a stressful life event, can influence mental health. Often called acculturative stress, it occurs during the process of adapting to a new culture (Berry et al., 1987). Refugees who leave their homelands because of extreme threat from political forces tend to experience more trauma, more undesirable change, and less control over the events that define their exits than do voluntary immigrants (Rumbaut, 1985; Meinhardt et al., 1986).

The psychological stress associated with immigration tends to be concentrated in the first three years after arrival in the United States (Vega & Rumbaut, 1991). According to studies of Southeast Asian refugees, an initial euphoria often characterizes the first year following migration, followed by a strong disenchantment and demoralization reaction during the second year. The third year includes a gradual return to well being and satisfaction (Rumbaut, 1985, 1989). This U-shaped curve has been observed in Cubans and Eastern Europeans (Portes & Rumbaut, 1990). Similarly, Ying (1988) finds that Chinese immigrants who have been in the United States less than one year have fewer symptoms of distress than those residing here for several years. Korean American immigrants have been found to have the highest levels of depressive symptoms in the one to two years following immigration; after three years, these symptoms remit (Hurh & Kim, 1988).

Although immigration can bring stress and subsequent psychological distress, research results do not suggest that immigration per se results in higher rates of mental disorders (e.g., Vega et al., 1998). However, as described in the sections on Asian Americans and Latinos, the traumas experienced by adults and children from war torn countries before and after immigrating to the United States seem to result in high rates of post traumatic stress disorder (PTSD) among these populations.

Overall Health Status

The burden of illness in the United States is higher in racial and ethnic minorities than whites. The National Institutes of Health (NIH) recently reported that compared with the majority populations, U.S. minority populations have shorter overall life expectancies and higher rates of cardiovascular disease, cancer, infant mortality, birth defects, asthma, diabetes, stroke, adverse con-sequences of substance abuse, and sexually transmitted diseases (DHHS, 2000; NIH, 2000). The list of illnesses is overpoweringly long.

Disparities in health status have led to high-profile research and policy initiatives. One long-standing policy initiative is Healthy People, a comprehensive set of national health objectives issued every decade by the Department of Health and Human Services. The most recent is Healthy People 2010, which contains both well defined objectives for reducing health disparities and the means for monitoring progress (DHHS, 2000).

Higher rates of physical (somatic) disorders among racial and ethnic minorities hold significant implications for mental health. For example, minority individuals who do not have mental disorders are at higher risk for developing problems such as depression and anxiety because chronic physical illness is a risk factor for mental disorders (DHHS, 1999; see also earlier section). Moreover, individuals from racial and ethnic minority groups who already have both a mental and a physical disorder (known as comorbidity) are more likely to have their mental disorder missed or misdiagnosed, owing to competing demands on primary care providers who are preoccupied with the treatment of the somatic disorder (Borowsky, et al., 2000; Rost et al., 2000). Even if their mental disorder is recognized and treated, people with comorbid disorders are saddled by more drug interactions and side effects, given their higher usage of medications. Finally, people with comorbid disorders are much more likely to be unemployed and disabled, compared with people who have a single disability (Druss et al., 2000).

Thus, poor somatic health takes a toll on mental health. And it is probable that some of the mental health disparities described in this Supplement are linked to the poorer somatic health status of racial and ethnic minorities. The interrelationships between mind and body are inescapably evident.

Culture of the Clinician

As noted earlier, a group of professionals can be said to have a "culture" in the sense that they have a shared set of beliefs, norms, and values. This culture is reflected in the jargon members of a group use, in the orientation and emphasis in their textbooks, and in their mindset, or way of looking at the world. Health professionals in the United States, and the institutions in which they train and practice, are rooted in Western medicine. The culture of Western medicine, launched in ancient Greece, emphasizes the primacy of the human body in disease. Further, Western medicine emphasizes the acquisition of knowledge through scientific and empirical methods, which hold objectivity paramount. Through these methods, Western medicine strives to uncover universal truths about disease, its causation, diagnosis, and treatment.

Around 1900, Western medicine started to conceptualize disease as affected by social, as well as by biological phenomena. Its scope began to incorporate wider questions of income, lifestyle, diet, employment, and family structure, thereby ushering in the broader field of public health (Porter, 1997) Mental health professionals trace their roots to Western medicine and, more particularly, to two major European milestones - the first forms of biological psychiatry in the mid-19th century and the advent of psychotherapy (or "talk therapy") near the end of that century (Shorter, 1997). The earliest forms of biological psychiatry primed the path for more than a century of advances in pharmacological therapy, or drug treatment, for mental illness. The original psychotherapy, known as psychoanalysis, was founded in Vienna by Sigmund Freud. While many forms of psychotherapy are available today, with vastly different orientations, all emphasize verbal communication between patient and therapist as the basis of treatment. Today's treatments for specific mental disorders also may combine pharmacological therapy and psychotherapy; this approach is known as multimodal therapy. These two types of treatment and the intellectual and scientific traditions that galvanized their development are an outgrowth of Western medicine.

To say that physicians or mental health professionals have their own culture does not detract from the universal truths discovered by their fields. Rather, it means that most clinicians share a worldview about the interrelationship among body, mind, and environment, informed by knowledge acquired through the scientific method. It also means that clinicians view symptoms, diagnoses, and treatments in a manner that sometimes diverges from their patients. Clinicians conceptions of disease and their responses to it unquestionably show the imprint of a particular culture, especially its individualist and activist therapeutic mentality," writes sociologist of medicine Paul Starr (1982).

Because of the professional culture of the clinician, some degree of distance between clinician and patient always exists, regardless of the ethnicity of each (Burkett, 1991). Clinicians also bring to the therapeutic setting their own personal cultures (Hunt, 1995; Porter, 1997). Thus, when clinician and patient do not come from the same ethnic or cultural background, there is greater potential for cultural differences to emerge. Clinicians may be more likely to ignore symptoms that the patient deems important, or less likely to understand the patient's fears, concerns, and needs. The clinician and the patient also may harbor different assumptions about what a clinician is supposed to do, how a patient should act, what causes the illness, and what treatments are available. For these reasons, DSM-IV exhorts clinicians to understand how their relationship with the patient is affected by cultural differences.

Communication

The emphasis on verbal communication is a distinguishing feature of the mental health field. The diagnosis and treatment of mental disorders depend to a large extent on verbal communication between patient and clinician about symptoms, their nature, intensity, and impact on functioning. While many mental health professionals strive to deliver treatment that is sensitive to the culture of the patient, problems can occur.

The emphasis on verbal communication yields greater potential for miscommunication when clinician and patient come from different cultural backgrounds, even if they speak the same language. Overt and subtle forms of miscommunication and misunderstanding can lead to misdiagnosis, conflicts over treatment, and poor adherence to a treatment plan. But when patient and clinician do not speak the same language, these problems intensify. The importance of cross cultural communication in establishing trusting relationships between clinician and patient is just beginning to be explored through research in family practice (Cooper-Patrick et al., 1999) and mental health.

Primary Care

Primary care is a critical portal to mental health treatment for ethnic and racial minorities. Minorities are more likely to seek help in primary care as opposed to specialty care, and cross cultural problems may surface in either setting (Cooper-Patrick et al., 1999). Primary care providers, particularly under the constraints of managed care, may not have the time or capacity to recognize and diagnose mental disorders or to treat them adequately, especially if patients have co-existing physical disorders (Rost et al., 2000). Some estimates suggest that about one-third to one-half of patients with mental disorders go undiagnosed in primary care settings (Higgins, 1994; Williams et al., 1999). Minority patients are among those at greatest risk of non-detection of mental disorders in primary care (Borowsky et al., 2000). Missed or incorrect diagnoses carry severe consequences if patients are given inappropriate or possibly harmful treatments, while their underlying mental disorder is left untreated.

Clinician Bias and Stereotyping

Misdiagnosis also can arise from clinician bias and stereotyping of ethnic and racial minorities. Clinicians often reflect the attitudes and discriminatory practices of their society (Whaley, 1998). This institutional racism was evident over a century ago with the establishment of a separate, completely segregated mental hospital in Virginia for African American patients (Prudhomme & Musto, 1973). While racism and discrimination have certainly diminished over time, there are traces today which are manifest in less overt medical practices concerning diagnosis, treatment, prescribing medications, and referrals (Giles et al., 1995; Shiefer, Escarce, & Schulman, 2000). One study from the mental health field found that African American youth were four times more likely than whites to be physically restrained after acting in similarly aggressive ways, suggesting that racial stereotypes of blacks as violent motivated the professional judgment to have them restrained (Bond et al., 1988). Another study found that white therapists rated a videotape of an African American client with depression more negatively than they did a white patient with identical symptoms (Jenkins-Hall & Sacco, 1991).

There is ample documentation that African American patients are subject to over diagnosis of schizophrenia. African Americans are also under diagnosed for bipolar disorder (Bell et al., 1980, 1981; Mukherjee, et al., 1983), depression, and, possibly, anxiety (Neal-Barnett & Smith, 1997; Baker & Bell, 1999; Borowsky et al., 2000). The problems extend beyond African Americans. Widely held stereotypes of Asian Americans as "problem free" may prompt clinicians to overlook their mental health problems (Takeuchi & Uehara, 1996).

To infer a role for bias and stereotyping by clinicians does not prove that it is actually occurring, nor does it indicate the extent to which it explains disparities in mental health services. Some of the racial and ethnic disparities described in this Supplement are likely the result of racism and discrimination by white clinicians; however, the limited research on this topic suggests that the issue is more complex. A large study of cardiac patients could not attribute African Americans' lower utilization of a cardiac procedure to the race of the physician. Lower utilization by African American versus white patients was independent of whether patients were treated by white or black physicians (Chen et al., 2001). The study authors suggested the possibility that institutional factors and attitudes that were common to black and white physicians contributed to lower rates of utilization by black patients. Some have suggested that what appears to be racial bias by clinicians might instead reflect biases of their socioeconomic status or their professional culture (Epstein & Ayanian, 2001). These biases, whether intentional or unintentional, may be more powerful influences on care than the influence of the clinician's own race or ethnicity.

Culture, Society, and Mental Health Services

Every society influences mental health treatment by how it organizes, delivers, and pays for mental health services. In the United States, services are financed and delivered in vastly different ways than in other nations. That organization was shaped by and reflects a unique set of historical, economic, political, and social forces, which were summarized in the SGR (DHHS, 1999). The mental health service system is a fragmented patchwork, often referred to as the "de facto mental health system" because of its lack of a single set of organizing principles (Regier et al., 1993). While this hybrid system serves a range of functions for many people, it has not successfully addressed the problem that people with the most complex needs and the fewest financial resources often find it difficult to use. This problem is magnified for minority groups. To understand the obstacles that minorities face, this section provides background on mental health service settings, financing, and the concept of culturally competent services.

Service Settings and Sectors

Mental health services are provided by numerous types of practitioners in a diverse array of environments, variously called settings and sectors. Settings range from home and community to institutions, and sectors include public or private primary care and specialty care. This section provides a broad overview of mental health services, patterns of use, and trends in financing.

The burgeoning types of community services available today stand in sharp contrast to the institutional orientation of the past. Propelled by reform movements, advocacy, and the advent of managed care, today's best mental health services extend beyond diagnosis and treatment to cover prevention and the fulfillment of broader needs, including housing and employment. Services are formal (provided by professionals) or informal (provided by lay volunteers). The most fundamental shift has been in the setting for service delivery, from the institution to the community. There are four major sectors for receiving mental health care:

• The specialty mental health sector is designed solely for the provision of mental health services. It refers to mental hospitals, residential treatment facilities, and psychiatric units of general hospitals. It also refers to specialized agencies and programs in the community, such as community mental health centers, day treatment programs, and rehabilitation programs. Within these settings, services are furnished by specialized mental health professionals, such as psychologists, psychiatric nurses, psychiatrists, and psychiatric social workers;
• The general medical and primary care sector offers a comprehensive range of health care services including, but not limited to, mental health services. Primary care physicians, nurse practitioners, internists, and pediatricians are the general types of professionals who practice in a range of settings that include clinics, offices, community health centers, and hospitals;
• The human services sector is made up of social welfare (housing, transportation, and employment), criminal justice, educational, religious, and charitable services. These services are delivered in a full range of settings - home, community, and institutions;
• The voluntary support network refers to self help groups and organizations devoted to education, communication, and support. Services provided by the voluntary support network are largely found in the community. Typically informal in nature, they often help patients and families increase knowledge, reduce feelings of isolation, obtain referrals to formal treatment, and cope with mental health problems and illnesses.

Consumers can exercise choice in treatment largely because of the range of effective treatments for mental illness and the diversity of settings and sectors in which these treatments are offered. Consumers can choose, too, between distinct treatment modalities, such as psychotherapy, counseling, pharmacotherapy (medications), or rehabilitation. For severe mental illnesses, however, all types are usually essential, as are delivery systems to integrate their services (DHHS, 1999).

Consumer preferences cannot necessarily be inferred from the types of treatment they actually use because costs, reimbursement, or availability of services - rather than preferences - may drive their utilization. For example, minority patients who wish to see mental health professionals of similar racial or ethnic back-grounds may often find it difficult or impossible, because most mental health practitioners are white. Because there are only 1.5 American Indian/Alaska Native psychiatrists per 100,000 American Indians/Alaska Natives in this country, and only 2.0 Hispanic psychiatrists per 100,000 Hispanics, the chance of an ethnic match between Native or Hispanic American patient and provider is highly unlikely (Manderscheid & Henderson, 1999).

Financing of Mental Health Services and Managed Care

Mental health services are financed from many funding streams that originate in the public and private sectors. In 1996, slightly more than half of the $69 billion in mental health spending was by public payers, including Medicaid and Medicare. The remainder came mostly from either private insurance (27%) or out of pocket payments (17%) by patients and their families (DHHS, 1999).

One of the most significant changes affecting both privately and publicly funded services has been the striking shift to managed care. Relatively uncommon two decades ago, managed care in some form now covers the majority of Americans, regardless of whether their care is paid for through the public or the private sector (Levit & Lundy, 1998). The term "managed care" technically refers to a variety of mechanisms for organizing, delivering, and paying for health services. It is attractive to purchasers because it holds the promise of containing costs, increasing access to care, improving coordination of care, promoting evidence based quality care, and emphasizing prevention. Attainment of these goals for all racial and ethnic groups is difficult to verify through research because of the breathtaking pace of change in the health care marketplace. Study in this area is also challenging because claims data are closely held by private companies and thus are often unavailable to researchers, and because insurers and providers often do not collect information about ethnicity or race (Fraser, 1997).

Almost 72 percent of Americans with health insurance in 1999 were enrolled in managed behavioral health organizations for mental or addictive disorders (OPEN MINDS, 1999). Managed care has far reaching implications for mental health services in terms of access, utilization, and quality, yet there has been only a limited body of research on its effectiveness in these areas (DHHS, 1999).

Through lower costs, managed care was expected to boost access to care, which is especially critical for racial and ethnic minorities. However, there is preliminary evidence that managed care is perceived by some racial and ethnic minorities as imposing more barriers to treatment than does fee for service care (Scholle & Kelleher, 1997; Provan & Carle, 2000). Yet, improved access alone will not eliminate disparities. Other compelling factors curtail utilization of services by racial and ethnic minorities, and they need to be addressed to reduce the gap between minorities and whites.

In terms of quality of care, the SGR noted ongoing efforts within behavioral health care to develop quality reporting systems. It also pointed out that existing incentives within and outside managed care do not encourage an emphasis on quality of care (DHHS, 1999). While the SGR concluded that there is little direct evidence of problems with quality in well implemented managed care programs, it cautioned that "the risk for more impaired populations and children remains a serious concern."

Finally, managed care has been coupled with legislative proposals to impose parity in financing of mental health services. Intended to reverse decades of inequity, parity seeks coverage for mental health services on a par with that for somatic (physical) illness. Managed care's potential to control costs through various management strategies that prevent overuse of services makes parity more economically feasible (DHHS, 1999). Studies described in the SGR found negligible cost increases under existing parity programs within several States. Further, several studies have shown that racial and ethnic disparities in access to health care and in treatment out comes are reduced or eliminated under equal access systems such as the Department of Defense health care system (Optenberg et al., 1995; Taylor et al., 1997), the VA medical system for some disease conditions, and in some health maintenance organizations (Tambor et al., 1994; Martin, Shelby, & Zhang, 1995; Clancy & Franks, 1997).

Demographic Trends

The United States is undergoing a major demographic transformation in racial and ethnic composition of its population. In 1990, 23 percent of U.S. adults and 31 percent of children were from racial and ethnic minority groups (Hollmann, 1993). In 25 years, it is projected that about 40 percent of adults and 48 percent of children will be from racial and ethnic minority groups (U.S. Census Bureau, 2000; Lewit & Baker, 1994). While these changes bring with them the enormous richness of diverse cultures, significant changes are needed in the mental health system to meet the associated challenges.

Diversity within Racial and Ethnic Groups

The four most recognized racial and ethnic minority groups are themselves quite diverse. For instance, Asian Americans and Pacific Islanders include at least 43 separate subgroups who speak over 100 languages. Hispanics are of Mexican, Puerto Rican, Cuban, Central and South American, or other Hispanic heritage (U.S. Census Bureau, 2000). American Indian/Alaskan Natives consist of more than 500 tribes with different cultural traditions, languages, and ancestry. Even among African Americans, diversity has recently increased as black immigrants arrive from the Caribbean, South America, and Africa. Some members of these subgroups have largely acculturated or assimilated into mainstream U.S. culture, whereas others speak English with difficulty and interact almost exclusively with members of their own ethnic group.

Impact of Immigration Laws

During the last century, U.S. immigration laws alternately closed and opened the doors of immigration to different foreign populations. For example, the 1924 Immigration Act established the National Origins System, which restricted annual immigration from any foreign country to 2 percent of that country's population living in the United States, as counted in the census of 1890. Since most of the foreign born counted in the 1890 census were from northern and western European countries, the 1924 Immigration Act reinforced patterns of white immigration and staved off immigration from other areas, including Asia, Latin America, and Africa.

Until the 1960s, approximately two-thirds of all legal immigrants to the United States were from Europe and Canada. The Immigration Act of 1965 replaced the National Origins System and allowed an annual immigration quota of 20,000 individuals from each country in the Eastern Hemisphere. The Act also gave preference to individuals in certain occupations. The effect was striking: Immigration from Asia skyrocketed from 6 percent of all immigrants in the 1950s to 37 percent by the 1980s. Yet another provision of the Act supported family reunification and gave preference to people with relatives in the United States, one factor behind the growth in immigration from Mexico and other Latin American countries (U.S. Census Bureau, 1999). Over this same period of time, the percentage of immigrants from Europe and Canada fell from 68 percent to 12 percent (U.S. Immigration and Naturalization Service, 1999).

In the past 20 years, immigration has led to a shift in the racial and ethnic composition of the United States not witnessed since the late 17th century, when black slaves became part of the labor force in the South (Muller, 1993). Though this wave of immigration is similar to the surge of immigration that occurred in the early part of this century, a critical difference is in the countries of origin. In the early 1900s, immigrants primarily came from Europe and Canada, while recent immigration is primarily from Asian and Latin American countries.

Overall, the racial and ethnic makeup of the United States has changed more rapidly since 1965 than during any other period in history. The reform in immigration policy in 1965, the increase in self identification by ethnic minorities, and the slowing of the country's birth rates, especially among non-Hispanic white Americans, have all led to an increasing, and increasingly diverse, racial and ethnic minority population in the United States.

Conclusions

• Culture influences many aspects of mental illness, including how patients from a given culture express and manifest their symptoms, their style of coping, their family and community supports, and their willingness to seek treatment. Likewise, the cultures of the clinician and the service system influence diagnosis, treatment, and service delivery. Cultural and social influences are not the only determinants of mental illness and patterns of service utilization for racial and ethnic minorities, but they do play important roles.
• Mental disorders are highly prevalent across all populations, regardless of race or ethnicity. Cultural and social factors contribute to the causation of mental illness, yet that contribution varies by disorder. Mental illness is considered the product of a complex interaction among biological, psychological, social, and cultural factors. The role of any one of these major factors can be stronger or weaker depending on the specific disorder.
• Within the United States, overall rates of mental disorders for most minority groups are largely similar to those for whites. This general conclusion does not apply to vulnerable, high need sub groups, who have higher rates and are often not captured in community surveys. The overall rates of mental disorder for many smaller racial and ethnic groups, most notably American Indians, Alaska Natives, Asian Americans and Pacific Islanders are not sufficiently studied to permit definitive conclusions.
• Ethnic and racial minorities in the United States face a social and economic environment of inequality that includes greater exposure to racism and discrimination, violence, and poverty, all of which take a toll on mental health. Living in poverty has the most measurable impact on rates of mental illness. People in the lowest stratum of income, education, and occupation are about two to three times more likely than those in the highest stratum to have a mental disorder.
• Racism and discrimination are stressful events that adversely affect health and mental health. They place minorities at risk for mental disorders such as depression and anxiety. Whether racism and discrimination can by themselves cause these disorders is less clear, yet deserves research attention.
• Stigma discourages major segments of the population, majority and minority alike, from seeking help. Attitudes toward mental illness held by minorities are as unfavorable, or even more unfavorable, than attitudes held by whites.
• Mistrust of mental health services is an important reason deterring minorities from seeking treatment. Their concerns are reinforced by evidence, both direct and indirect, of clinician bias and stereotyping. The extent to which clinician bias and stereotyping explain disparities in mental health services is not known.
• The cultures of ethnic and racial minorities alter the types of mental health services they use. Cultural misunderstandings or communication problems between patients and clinicians may prevent minorities from using services and receiving appropriate care.

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