0
Get Alert
Please Wait... Processing your request... Please Wait.
You must sign in to sign-up for alerts.

Please confirm that your email address is correct, so you can successfully receive this alert.

1
Article   |    
Cultural Competence: A Literature Review and Conceptual Model for Mental Health Services
Mario Hernandez, Ph.D.; Teresa Nesman, Ph.D.; Debra Mowery, Ph.D.; Ignacio D. Acevedo-Polakovich, Ph.D.; Linda M. Callejas, M.A.
Psychiatric Services 2009; doi: 10.1176/appi.ps.60.8.1046
View Author and Article Information

Dr. Hernandez, Dr. Nesman, Dr. Mowery, and Ms. Callejas are affiliated with the Louis de la Parte Florida Mental Health Institute, University of South Florida, Tampa. Dr. Acevedo-Polakovich is with the Department of Psychology, Central Michigan University, Mt. Pleasant. Send correspondence to Dr. Hernandez, Department of Child and Family Studies, Louis de la Parte Florida Mental Health Institute, 13301 Bruce B. Downs Blvd., Tampa, FL 33612-3807 (e-mail: hernande@fmhi.usf.edu).

This article presents a conceptual model of organizational cultural competence for use in mental health services that resulted from a comprehensive review of the research literature. The model identifies four factors associated with cultural competence in mental health services (community context, cultural characteristics of local populations, organizational infrastructure, and direct service support) and redefines cultural competence as the degree of compatibility among these factors. A strength of this model of organizational cultural competence is that it facilitates future research and practice in psychiatric services settings and links culturally competent practices to service parity. (Psychiatric Services 60:1046–1050, 2009)

Abstract Teaser
Figures in this Article

Among individuals who are in need of mental health services, members of many U.S. racial-ethnic minority groups face significant disparities compared with Americans with European origins (1). For instance, compared with European Americans with co-occurring depression and substance abuse, African Americans and Latinoswith the same co-occurrence tend to have less access to selective serotonin reuptake inhibitors (2), which are often recommended as a first-line treatment for individuals with co-occurring depression and substance use disorder (3). Even when services are available to members of U.S. racial-ethnic minority groups, they often are not accessible to large subsets of those populations. For example, compared with their English-proficient counterparts, Asians, Pacific Islanders, and Latinos with a mental health need andlimited English proficiency tend to be less likely to receive services (4). Given the limited English proficiency of a large proportion of Asians, Pacific Islanders, and Latinos, their limited ability to access mental health services may contribute to overall racial-ethnic disparities in mental health services (4).

It often hasbeen suggested that increasing cultural competence in providing psychiatric services can contribute to the reduction of existing mental health service disparities (5,6). According to one popular definition, cultural competence in mental health services occurs when a set of congruent behaviors, attitudes, and policies come together in a system, an agency, or among professionals to enable effective cross-cultural work (7). Although the proposition that increased cultural competence in providing psychiatric services can reduce existing disparities is appealing, cultural competence lacks a clear means of operationalization that can direct research and practice (8,9,10).

This article summarizes a model for cultural competence in mental health services. The model has emerged from research that seeks to operationalize cultural competence in order to facilitate its understanding and implementation in behavioral health organizations (11). The model organizes the findings from a literature review that examined over 1,100 articles on the topic of cultural competence in mental health services for racially and ethnically diverse groups in the United States. The goal of the review was to identify and describe measurable factors associated with cultural competence in mental health services and the relations among these factors (11,12). This review was part of a larger study that focused on identifying organizational practices to operationalize cultural competence and reduce mental health service disparities by improving service accessibility (13). A full description of the study methodology can be obtained from source materials and by direct inquiry to the authors.

The available literature suggests that disparities in delivery of mental health services are driven by incompatibility between available services and the culture and social context of the communities being served. Indeed, results of the literature review led to redefining cultural competence in mental health services as the degree of compatibility between the cultural and linguistic characteristics of a community and the manner in which the combined policies, structures, and processes underlying local mental health services seek to make these services available, accessible, and utilized (11).

The model arising from our review of the literature suggests that cultural competence occurs when there is compatibility among four important factors: community context, cultural characteristics of local populations, organizational infrastructure, and direct service support (11). These factors and their role in ensuring culturally competent mental health services are described below.

+

Community context

Community context provides an overall background for understanding psychiatric service organizations and their target populations. Organizations function within larger community, city, county, state, and national environments that affect their efforts to serve their local community (12). Individuals' responses to mental health issues also occur within the framework of the larger social environment (14). Because of this system,community context affects the manner inwhich racially and ethnically diverse individuals come into contact with services (14). For example, when compared with their European-American peers, African-American adolescents are more likely to enter mental health services through involuntary commitment, such as juvenile justice (14,15,16,17,18). Similarly, compared with their European-American peers, Native-American adolescents are more likely to be removed from their homes in order to receive services and are overallless likely to receive services. These differing service pathways are influenced by family choices, cultural factors, and by the interaction between contextual and organizational factors, including service availability and the availability of social networks that provide referrals to services (14).

+

Cultural characteristics of local populations

Culture has a pervasive influence over important aspects of people's everyday experience,including their perceptions of, and interactions with, mental health services (14,19,20). For instance, cultural differencesinfluence mental health help-seeking strategies, affecting variables such as problem identification, problem definition, and treatment or provider choices (14). Simply stated, culture influences what gets defined as a problem, how the problem is understood,and which solutions to theproblem are acceptable. Culture also affects mental health services when there are cultural differences between providers andindividualsreceiving services. When unacknowledged and unaddressed, these differences have been found to perpetuate disparities through misdiagnosis and mistreatment (19,20,21,22). Culturally competent mental health services are to a great extenttied to aservice organization's ability to appropriately understand and respond to the cultural characteristics of the community it serves (11).

One important caveat whenproviding servicesto communities in which there is inequitable distribution of social capital across cultural groups, as is the case for many U.S. communities, is to avoid confusing the influences of culturewith those of socioeconomic status (14), particularly because socioeconomic status also influences important service factors. Individuals with lower socioeconomic status tend to face significantly more service access barriers, including a lack of insurance, time constraints, and transportation limitations (23). These patternsunderscore the importance of attending to both the joint and the independent effects of socioeconomic status and culture (24).

In summary, a community's cultural characteristics meaningfully influence many factors associated with mental health service disparities. To overcome these disparities, providers must be attentive and responsive to these cultural characteristics and their effects and consider them in the context of other powerful contextual factors, including socioeconomic status (11,24).

+

Organizational infrastructure

There are two service domainsthat shouldbe considered when attempting to develop culturally competent mental health services, and as explained below, such services reflect compatibility between and within these service domains. The first domain, organizational infrastructure, includes eight interrelated components of psychiatric services organizations. Each component and its relevance to culturally competent service delivery are introduced below.

Values. Values are reflected in service organizations' mission and vision statements, documentation, the stated beliefs of administrative and direct service personnel, and the documented manner in which an organization acts on these beliefs (25,26). In culturally competent service organizations, these value markers articulate the importance of cultural competence and reflect the organization's commitment to culturally competent services and the manner in which these services will be provided (27).

Communication. Communication refers to the exchange of information between a service organization and the community, among partner organizations, and within one organization (28). Culturally competent communication practices foster learning and direct exchanges of information both within the organization and between the organization and the community it serves (29).

Community participation. This component refers to the level of engagement between a service organization and the community (30). Culturally competent service organizations move beyond community outreach and into strategies that involve community members in providing a large degree of input into the variety of and manner in which services are provided (25,31,32).

Governance. Governance refers to the processes through which a service organization acts to institute policies, procedures, and goals (27,33). Organizations that provide culturally competent services typically have in place rules and plans to guide the provision of these services (31,34).

Planning and evaluation. The methods and procedures for an organization's systematic data collection regarding its target community are called planning and evaluation (25,31,35). Common planning and evaluation tools include assessments of community needs and an organization's self-assessment of cultural competence levels (27,34). Culturally competent organizations tend to include communities as fully contributing partners in planning and evaluation processes and to implement data collection approaches that reflect the relation between the community context and the services being provided (27).

Human resources. Human resource practices facilitate culturally competent services by ensuring that the organization's employees have the requisite knowledge and skills to deliver these services (27). This includes recruiting and hiring personnel versed in the languages and cultures that prevail in the community (36,37), providing comprehensive opportunities for cultural competence training (32,35,36), and reflecting the importance of cultural competence through performance incentives, in personnel evaluations, and in the criteria for personnel retention and promotion (34).

Service array. Culturally competent service organizations adapt their service array in response to a community's needs and practices (11). For instance, some service organizations increase their multilingual and multicultural capacity in order to ensure provision of consistently high-quality services in culturally and linguisticallyheterogeneous communities (27,34). Other organizations incorporate informal supports into their service array in order to increase accessibility to and adequacy of services (34). Informal supports are naturally existing agents that are accessed by community members in times of need and caninclude family, friends, religious organizations, cultural healers, and other human services.

Technical support. To ensure cultural competence, service organizations must ensurethe availability of assets or supplies necessary to the community. These include financial supports, staffing, linkages, and technology (25,27).

+

Direct service support

Direct service support, the second organizational domain to be considered when attempting to develop culturally competent mental health services, groups together three interrelated organizational functions: service availability, service accessibility, and service utilization (11,12). Each function and its relevance to culturally competent service delivery are introduced below.

Availability. Cultural competence in service availability involves ensuring that the range and capacity of available services adequately reflects the needs of the community being served (11).

Accessibility. Accessibility involves facilitating individuals' ability to successfully enter, navigate, and exit needed services and supports (11). Examples of adaptations that service organizations can make to increase cultural competence in service accessibility include providing and promoting services at times and locations that are convenient to the community, such as at community events or through home-based services (38,39); ensuring that services and supporting materials are available in the languages used by the community (5,31); and incorporating cultural healing traditions into the service array (29).

Utilization. As an organizational process, utilization involves the promotion of service use in the community and the facilitation of organizational accountability by tracking service use patterns (11). Examples of adaptations that increase cultural competence in service use include providing reminder calls for appointments and providing transportation to services (40,41,42). Patterns tracked by culturally competent service organizations include the length of time in service, client retention rates, client dropout rates, and rates of client return (41,43,44).

+

Compatibility issues

As underscored by the model's revised definition of cultural competence, the available literature highlights the importance of creating compatibility among service domains and community characteristics in order to reduce existing disparities (5,6,11). In one striking illustration of the importance of ensuring compatibility, results of a meta-analysis of 76 published studies found that services adapted to ensure compatibility with the cultural characteristics of specific communities were four times more effective than services broadly adapted for individuals from a variety of cultural backgrounds (45).

An example of the need for compatibility among service factors is as follows: An organization decides to increase service access by developing a one-stop family services center. However, a failure to clearly articulate and operationalize cultural competence values prevents community participation in service planning and development. In turn, this lack of input prevents the identification of a need for the availability of bilingual services and increases community mistrust of the service organization. Ultimately, the community's lack of opportunity to provide input and its growing mistrust drive service utilization levels far below expectations and contribute to the perpetuation of disparities in psychiatric and mental health services.

+

Tracking parity: organizational cultural competence outcomes

The available literature suggests that increased cultural competence in mental health services leads to reduced mental health disparities (43,46). However, disparities can exist across a wide variety of outcomes associated with mental health and mental health services (47). For this reason, in order to track disparities, outcomes should be measured at multiple levels. Organization-level outcomes include rates of access, client retention, and client no-shows (41,42,43). At the population level, a primary outcome is service use, which includes attending to overall rates of use across community subgroupsand to potential disproportionalities in use ofspecific types of services (14). At the service-recipient level, outcomes include satisfaction with services, clinical outcomes, social functioning, and client empowerment (28,48,49).

African American Family Services (AAFS), a Minneapolis, Minnesota, agency focused on the mental health needs of African Americans, provides a useful example of organizational cultural competence in mental health services.Regarding the first service domain, infrastructure, AAFS values and principles define their target community, espouse a commitment toculturally specificservices, and enable the achievement of culturally specific services.Planning and evaluation at AAFS feature open meetings with their target communities where community issues and ways in which these issues could be addressed by AAFS are discussed. By emphasizing hiring from within the community, AAFS human resources practices have led to a staff that is racially and ethnically representative of the community. AAFS fosters culturally competentcommunity participation and communicationby contributing to community events and fairs, developing partnerships with other local organizations, supporting staffinvolvement inlocal and regional councils and committees, and interacting closely with community media.AAFS offers a broad service array,including cultural adaptations of traditional mental health practices and additional services based on programs developed and supported by the community. Technical support for culturally competent services is evidentthrough ongoing training of existing staff, reflecting the organization'sassumption that culturally specific services result from deliberateefforts and are not necessarily achieved by focusing solely on demographic representation of the service population.

In terms of the second service domain, direct service support, AAFS ensures that service availability corresponds to community needs through ongoing data collection and service development. For instance, a needs-monitoring exercise with local family courts led to domestic violence services. AAFSfacilitates access by allowing walk-in appointments, placing its offices within the community, providing expanded hours (evenings and weekends), and delivering services in a variety of settings already frequented by the community, including primary careoffices, schools, other organizations' service delivery sites, and religious institutions that are important in the community. After identifying utilization gaps among adolescents and individuals with chronic and severe mental health problems, AAFS implemented an incentive program that rewards participation with gift certificates and other appropriate inducements.

Based on theavailable research literature, the model described in this article directly addresses a common criticism of cultural competence as a response to mental health service disparities by setting the foundation for a measurable approach to the pursuit of cultural competence in mental health care.It should be noted that this model places previous conceptualizations of cultural competence, such as characteristics of individual practitioners (6) or of specific service practices (5), within the broader context of the organization in which they exist. By doing so, the success of efforts to develop a culturally competent psychiatric practitioner community or to disseminate culturally competent psychiatric service practices may be meaningfully influenced by the overall ability of the service organization to recognize, value, and respond to the needs of the particular cultural communities being served.

In contrast to other models' focus on broad cultural values, the model described here highlights that cultural competence is demonstrated by understanding and responding to local communities' culturally influencedvalues, needs, and attitudes toward service. In doing so, the model expands the scope of cultural competence in two important ways. First, it facilitates culturally competent services in contexts often overlooked by overly broad approaches (for example, small ethnic communities and subcultures within larger ethnic groups). Second, it highlights cultural competenceas an inherent aspect of all organizations providing mental health services, not only those serving racial and ethnic minority groups. In this sense, the model avoids a common tendency to exoticize culture by considering it only as a factor affecting the care of racial-ethnic minority populations rather than as a dynamic set of factors that have a pervasive influence on important aspects of all individuals' everyday experience (50).

Although the model described identifies measurable factors associated with culturally competent services, further workmust determine the best approaches to measuring these factors, thereby facilitatingresearch and organizational practice. In particular, research is needed to examine the frequent suggestion that increased cultural competence in mental health services can reduce disparities in delivery of existing services. Ultimately, the model's value will depend on the results and relevance of such efforts. Nevertheless, the model provides direction for future workaimed at ensuring that themental health needs of large segments of theU.S. population are no longermisunderstood and unmet.

This research was funded in part by grant H133B040024 from the National Institute on Disability and Rehabilitation Research, U.S. Department of Education, and from the Center for Mental Health Services, Substance Abuse and Mental Health Services Administration.

The authors report no competing interests.

Atdjian S, Vega WA: Disparities in mental health treatment in US racial and ethnic minority groups: implications for psychiatrists. Psychiatric Services 56:1600–1602, 2005
 
Knudsen HK, Ducharme LJ, Roman PM: Racial and ethnic disparities in SSRI availability in substance abuse treatment. Psychiatric Services 58:55–62, 2007
 
Nunes EV, Levin FR: Treatment of depression in patients with alcohol and other drug dependence. JAMA 291:1887–1896, 2004
 
Sentell T, Shumway M, Snowden L: Access to mental health treatment by English language proficiency and race/ethnicity. Journal of General Internal Medicine 22(suppl 2):289–293, 2007
 
Brach C, Fraserirector I: Can cultural competency reduce racial and ethnic health disparities? A review and conceptual model. Medical Care Research and Review 57 (suppl 1):181–217, 2000
 
Lu FG, Primm A: Mental health disparities, diversity, and cultural competence in medical student education: how psychiatry can play a role. Academic Psychiatry 30:9–15, 2006
 
Cross TL, Bazron BJ, Dennis KW: Towards a Culturally Competent System of Care: Vol I. A Monograph on Effective Services for Minority Children Who Are Severely Emotionally Disturbed. Washington, DC, Georgetown University Child Development Center, CASSP Technical Assistance Center, 1989
 
Geron SM: Cultural competency: how is it measured? Does it make a difference? Generations 62:39–45, 2002
 
Sue DW: Multidimensional facets of cultural competence. Counseling Psychologist 29:790–821, 2001
 
Vega WA, Lopez SR: Priority issues in Latino mental health services research. Mental Health Services Research 3:189–200, 2001
 
Hernandez M, Nesman T, Isaacs M, et al: Examining the Research Base Supporting Culturally-Competent Children's Mental Health Services. FMHI pub no 240-1. Tampa, University of South Florida, Louis de la Parte Florida Mental Health Institute, Research and Training Center for Children's Mental Health, 2006
 
Harper M, Hernandez M, Nesman T, et al: Organizational Cultural Competence: A Review of Assessment Protocols. FMHI pub no 240-2. Tampa, University of South Florida, Louis de la Parte Florida Mental Health Institute, Research and Training Center for Children's Mental Health, 2006
 
Study 5: Accessibility of Mental Health Services: Identifying and Measuring Organizational Factors Associated With Reducing Mental Health Disparities in the Application for a Rehabilitation Research and Training Center for Developing and Implementing Integrated Systems of Care for Child and Adolescent Mental Health. CFDA 84.133B-5. Tampa, University of South Florida, Louis de la Parte Florida Mental Health Institute, Research and Training Center for Children's Mental Health, 2004
 
Cauce AM, Domenech-Rodriguez M, Paradise M, et al: Cultural and contextual influences in mental health help seeking: a focus on ethnic minority youth. Journal of Consulting and Clinical Psychology 70:44–55, 2002
 
Fabrega H, Ulrich R, Mezzich JE: Do Caucasian and black adolescents differ at psychiatric intake? Journal of the American Academy of Child and Adolescent Psychiatry 32:407–413, 1993
 
McCabe K, Yeh M, Hough RL, et al: Racial ethnic representation across five public sectors of care for youth. Journal of Emotional and Behavioral Disorders 7:72–82, 1999
 
Takeuchi D, Bui KT, Kim L: The referral of minority adolescents to community mental health centers. Journal of Health and Social Behavior 34:153–164, 1993
 
Yeh M, McCabe K, Hurlburt M, et al: Referral sources, diagnoses, and service types of youth in public outpatient mental health care: a focus on ethnic minorities. Journal of Behavioral Health Services and Research 29:45–60, 2002
 
Mental Health: Culture, Race, and Ethnicity. Rockville, Md, US Department of Health and Human Services, 2001
 
Achieving the Promise: Transforming Mental Health Care in America. Pub no SMA-03-3832. Rockville, Md, Department of Health and Human Services, President's New Freedom Commission on Mental Health, 2003
 
Balsa AI, McGuire TG: Prejudice, clinical uncertainty and stereotyping as sources of health disparities. Journal of Health Economics 22:89–116, 2003
 
Institute of Medicine: Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care.Washington, DC, National Academies Press, 2002
 
Alvidrez J: Ethnic variations in mental health attitudes and service use among low-income African American, Latina, and European American young women. Community Mental Health Journal 35:515–530, 1999
 
Report of the APA Task Force on Socioeconomic Status. Washington, DC, American Psychological Association, Task Force on Socioeconomic Status, 2007
 
Mason JL: Cultural Competence Self-Assessment Questionnaire: A Manual for Users. Portland, Ore, Research and Training Center on Family Support and Children's Mental Health, 1995
 
National Center for Cultural Competence: Cultural Competence Policy Assessment. Washington, DC, Georgetown University, Center for Child and Human Development, 2002
 
Lewin Group: Indicators of Cultural Competence in Health Care Delivery Organizations: An Organizational Cultural Competence Assessment Profile. Rockville, Md, US Department of Health and Human Services, 2002
 
Siegel C, Chambers ED, Haugland G, et al: Performance measures of cultural competency in mental health organizations. Administration and Policy in Mental Health 28:91–106, 2000
 
Isaacs MR, Huang LN, Hernandez M, et al: Services for youth and their families in diverse communities; in System of Care Handbook: Transforming Mental Health Services for Children, Youth, and Families. Edited by Stroul BA, Blau GM. Baltimore, Brookes, 2008
 
Tool Summary: CLAS Standards Assessment Tool. Washington, DC, Office of Minority Health. Available at www.qsource.org/uqiosc/CLAS Standards Assess Tool.doc
 
Assessment Guidelines for Developing a Multiculturally Competent Service System for an Organization or Program. Hartford, Connecticut Department of Children and Families, Nov 2002. Available at www.ct.gov/dcf/cwp/view.asp?a=2546&q=314458
 
Weiss CI, Minsky S: Program Self-Assessment Survey for Cultural Competence: A Manual. Trenton, New Jersey Division of Mental Health Services, 1996
 
Final Report: Developing a Self-Assessment Tool for Culturally and Linguistically Appropriate Services in Local Public Health Agencies. Bethesda, Md, COSMOS Corp, Dec 2003. Available at www.cosmoscorp.com/publications.html
 
Siegel C, Haugland G, Chambers ED: Cultural Competency and Data Strategies to Assess the Quality of Services in Mental Health Systems of Care: A Project to Select and Benchmark Performance Measures of Cultural Competency. Orangeburg, New York Office of State Mental Health, 2002
 
Cultural Competence Agency Self-Assessment Instrument (Revised). Washington, DC, Child Welfare League of America Press, 2002
 
Andrulis D, Delbanco T, Avakian L, et al: Conducting a Cultural Competence Self-Assessment. Cambridge, Mass, Manager's Electronic Resource Center, Management Sciences for Health. Available at erc.msh.org/provider/andrulis.pdf
 
Organizational Self-Study on Cultural Competence for Agencies Addressing Child Abuse and Neglect. Portland, Ore, North West Indian Child Welfare Association, 1991
 
Bean RA, Perry BJ, Bedell TM: Developing culturally competent marriage and family therapists: treatment guidelines for non-African-American therapists working with African-American families. Journal of Marital and Family Therapy 28:153–164, 2002
 
McKay MM, Pennington J, Lynn CJ, et al: Understanding urban child mental health service use: two studies of child, family, and environmental correlates. Journal of Behavioral Health Services and Research 28:475–483, 2001
 
Manoleas P, Organista K, Negron-Velasquez G, et al: Characteristics of Latino mental health clinicians: a preliminary examination. Community Mental Health Journal 36:383–394, 2000
 
McKay MM, Stoewe J, McCadam K, et al: Increasing access to child mental health services for urban children and their caregivers. Health and Social Work 23:9–15, 1998
 
Friedmann PD, D'Aunno TA, Jin L, et al: Medical and psychosocial services in drug abuse treatment: do stronger linkages promote client utilization? Health Services Research 35:443–465, 2000
 
Matsuoka JK, Breaux C, Ryujin DH: National utilization of mental health services by Asian Americans/Pacific Islanders. Journal of Community Psychology 25:141–145, 1997
 
Sue S, Fujino DC, Hu LT, et al: Community mental health services for ethnic minority groups: a test of the cultural responsiveness hypothesis. Journal of Consulting and Clinical Psychology 59:533–540, 1991
 
Griner D, Smith TB: Culturally adapted mental health interventions: a meta-analytic review. Psychotherapy: Theory, Research, Practice, Training 43:531–548, 2006
 
Diaz E, Prigerson H, Desai R, et al: Perceived needs and service use of Spanish speaking monolingual patients followed at a Hispanic clinic. Community Mental Health Journal 37:335–346, 2001
 
Takeuchi DT, Sue S, Yeh M: Return rates and outcomes from ethnicity-specific mental health programs in Los Angeles. American Journal of Public Health 85:638–643, 1995
 
Akutsu PD, Snowden LR, Organista KC: Referral patterns in ethnic specific and mainstream programs for ethnic minorities and whites.Journal of Counseling Psychology 43:56–64, 1996
 
Snell-Johns J, Mendez JL, Smith BH: Evidence-based solutions for overcoming access barriers, decreasing attrition, and promoting change with underserved families.Journal of Family Psychology 18:19–35, 2004
 
López SR, Guarnaccia PJ: Cultural psychopathology: uncovering the social world of mental illness. Annual Review of Psychology 51:571–598, 2000
 
+

References

Atdjian S, Vega WA: Disparities in mental health treatment in US racial and ethnic minority groups: implications for psychiatrists. Psychiatric Services 56:1600–1602, 2005
 
Knudsen HK, Ducharme LJ, Roman PM: Racial and ethnic disparities in SSRI availability in substance abuse treatment. Psychiatric Services 58:55–62, 2007
 
Nunes EV, Levin FR: Treatment of depression in patients with alcohol and other drug dependence. JAMA 291:1887–1896, 2004
 
Sentell T, Shumway M, Snowden L: Access to mental health treatment by English language proficiency and race/ethnicity. Journal of General Internal Medicine 22(suppl 2):289–293, 2007
 
Brach C, Fraserirector I: Can cultural competency reduce racial and ethnic health disparities? A review and conceptual model. Medical Care Research and Review 57 (suppl 1):181–217, 2000
 
Lu FG, Primm A: Mental health disparities, diversity, and cultural competence in medical student education: how psychiatry can play a role. Academic Psychiatry 30:9–15, 2006
 
Cross TL, Bazron BJ, Dennis KW: Towards a Culturally Competent System of Care: Vol I. A Monograph on Effective Services for Minority Children Who Are Severely Emotionally Disturbed. Washington, DC, Georgetown University Child Development Center, CASSP Technical Assistance Center, 1989
 
Geron SM: Cultural competency: how is it measured? Does it make a difference? Generations 62:39–45, 2002
 
Sue DW: Multidimensional facets of cultural competence. Counseling Psychologist 29:790–821, 2001
 
Vega WA, Lopez SR: Priority issues in Latino mental health services research. Mental Health Services Research 3:189–200, 2001
 
Hernandez M, Nesman T, Isaacs M, et al: Examining the Research Base Supporting Culturally-Competent Children's Mental Health Services. FMHI pub no 240-1. Tampa, University of South Florida, Louis de la Parte Florida Mental Health Institute, Research and Training Center for Children's Mental Health, 2006
 
Harper M, Hernandez M, Nesman T, et al: Organizational Cultural Competence: A Review of Assessment Protocols. FMHI pub no 240-2. Tampa, University of South Florida, Louis de la Parte Florida Mental Health Institute, Research and Training Center for Children's Mental Health, 2006
 
Study 5: Accessibility of Mental Health Services: Identifying and Measuring Organizational Factors Associated With Reducing Mental Health Disparities in the Application for a Rehabilitation Research and Training Center for Developing and Implementing Integrated Systems of Care for Child and Adolescent Mental Health. CFDA 84.133B-5. Tampa, University of South Florida, Louis de la Parte Florida Mental Health Institute, Research and Training Center for Children's Mental Health, 2004
 
Cauce AM, Domenech-Rodriguez M, Paradise M, et al: Cultural and contextual influences in mental health help seeking: a focus on ethnic minority youth. Journal of Consulting and Clinical Psychology 70:44–55, 2002
 
Fabrega H, Ulrich R, Mezzich JE: Do Caucasian and black adolescents differ at psychiatric intake? Journal of the American Academy of Child and Adolescent Psychiatry 32:407–413, 1993
 
McCabe K, Yeh M, Hough RL, et al: Racial ethnic representation across five public sectors of care for youth. Journal of Emotional and Behavioral Disorders 7:72–82, 1999
 
Takeuchi D, Bui KT, Kim L: The referral of minority adolescents to community mental health centers. Journal of Health and Social Behavior 34:153–164, 1993
 
Yeh M, McCabe K, Hurlburt M, et al: Referral sources, diagnoses, and service types of youth in public outpatient mental health care: a focus on ethnic minorities. Journal of Behavioral Health Services and Research 29:45–60, 2002
 
Mental Health: Culture, Race, and Ethnicity. Rockville, Md, US Department of Health and Human Services, 2001
 
Achieving the Promise: Transforming Mental Health Care in America. Pub no SMA-03-3832. Rockville, Md, Department of Health and Human Services, President's New Freedom Commission on Mental Health, 2003
 
Balsa AI, McGuire TG: Prejudice, clinical uncertainty and stereotyping as sources of health disparities. Journal of Health Economics 22:89–116, 2003
 
Institute of Medicine: Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care.Washington, DC, National Academies Press, 2002
 
Alvidrez J: Ethnic variations in mental health attitudes and service use among low-income African American, Latina, and European American young women. Community Mental Health Journal 35:515–530, 1999
 
Report of the APA Task Force on Socioeconomic Status. Washington, DC, American Psychological Association, Task Force on Socioeconomic Status, 2007
 
Mason JL: Cultural Competence Self-Assessment Questionnaire: A Manual for Users. Portland, Ore, Research and Training Center on Family Support and Children's Mental Health, 1995
 
National Center for Cultural Competence: Cultural Competence Policy Assessment. Washington, DC, Georgetown University, Center for Child and Human Development, 2002
 
Lewin Group: Indicators of Cultural Competence in Health Care Delivery Organizations: An Organizational Cultural Competence Assessment Profile. Rockville, Md, US Department of Health and Human Services, 2002
 
Siegel C, Chambers ED, Haugland G, et al: Performance measures of cultural competency in mental health organizations. Administration and Policy in Mental Health 28:91–106, 2000
 
Isaacs MR, Huang LN, Hernandez M, et al: Services for youth and their families in diverse communities; in System of Care Handbook: Transforming Mental Health Services for Children, Youth, and Families. Edited by Stroul BA, Blau GM. Baltimore, Brookes, 2008
 
Tool Summary: CLAS Standards Assessment Tool. Washington, DC, Office of Minority Health. Available at www.qsource.org/uqiosc/CLAS Standards Assess Tool.doc
 
Assessment Guidelines for Developing a Multiculturally Competent Service System for an Organization or Program. Hartford, Connecticut Department of Children and Families, Nov 2002. Available at www.ct.gov/dcf/cwp/view.asp?a=2546&q=314458
 
Weiss CI, Minsky S: Program Self-Assessment Survey for Cultural Competence: A Manual. Trenton, New Jersey Division of Mental Health Services, 1996
 
Final Report: Developing a Self-Assessment Tool for Culturally and Linguistically Appropriate Services in Local Public Health Agencies. Bethesda, Md, COSMOS Corp, Dec 2003. Available at www.cosmoscorp.com/publications.html
 
Siegel C, Haugland G, Chambers ED: Cultural Competency and Data Strategies to Assess the Quality of Services in Mental Health Systems of Care: A Project to Select and Benchmark Performance Measures of Cultural Competency. Orangeburg, New York Office of State Mental Health, 2002
 
Cultural Competence Agency Self-Assessment Instrument (Revised). Washington, DC, Child Welfare League of America Press, 2002
 
Andrulis D, Delbanco T, Avakian L, et al: Conducting a Cultural Competence Self-Assessment. Cambridge, Mass, Manager's Electronic Resource Center, Management Sciences for Health. Available at erc.msh.org/provider/andrulis.pdf
 
Organizational Self-Study on Cultural Competence for Agencies Addressing Child Abuse and Neglect. Portland, Ore, North West Indian Child Welfare Association, 1991
 
Bean RA, Perry BJ, Bedell TM: Developing culturally competent marriage and family therapists: treatment guidelines for non-African-American therapists working with African-American families. Journal of Marital and Family Therapy 28:153–164, 2002
 
McKay MM, Pennington J, Lynn CJ, et al: Understanding urban child mental health service use: two studies of child, family, and environmental correlates. Journal of Behavioral Health Services and Research 28:475–483, 2001
 
Manoleas P, Organista K, Negron-Velasquez G, et al: Characteristics of Latino mental health clinicians: a preliminary examination. Community Mental Health Journal 36:383–394, 2000
 
McKay MM, Stoewe J, McCadam K, et al: Increasing access to child mental health services for urban children and their caregivers. Health and Social Work 23:9–15, 1998
 
Friedmann PD, D'Aunno TA, Jin L, et al: Medical and psychosocial services in drug abuse treatment: do stronger linkages promote client utilization? Health Services Research 35:443–465, 2000
 
Matsuoka JK, Breaux C, Ryujin DH: National utilization of mental health services by Asian Americans/Pacific Islanders. Journal of Community Psychology 25:141–145, 1997
 
Sue S, Fujino DC, Hu LT, et al: Community mental health services for ethnic minority groups: a test of the cultural responsiveness hypothesis. Journal of Consulting and Clinical Psychology 59:533–540, 1991
 
Griner D, Smith TB: Culturally adapted mental health interventions: a meta-analytic review. Psychotherapy: Theory, Research, Practice, Training 43:531–548, 2006
 
Diaz E, Prigerson H, Desai R, et al: Perceived needs and service use of Spanish speaking monolingual patients followed at a Hispanic clinic. Community Mental Health Journal 37:335–346, 2001
 
Takeuchi DT, Sue S, Yeh M: Return rates and outcomes from ethnicity-specific mental health programs in Los Angeles. American Journal of Public Health 85:638–643, 1995
 
Akutsu PD, Snowden LR, Organista KC: Referral patterns in ethnic specific and mainstream programs for ethnic minorities and whites.Journal of Counseling Psychology 43:56–64, 1996
 
Snell-Johns J, Mendez JL, Smith BH: Evidence-based solutions for overcoming access barriers, decreasing attrition, and promoting change with underserved families.Journal of Family Psychology 18:19–35, 2004
 
López SR, Guarnaccia PJ: Cultural psychopathology: uncovering the social world of mental illness. Annual Review of Psychology 51:571–598, 2000
 
+
+

CME Activity

There is currently no quiz available for this resource. Please click here to go to the CME page to find another.
Submit a Comments
Please read the other comments before you post yours. Contributors must reveal any conflict of interest.
Comments are moderated and will appear on the site at the discertion of APA editorial staff.

* = Required Field
(if multiple authors, separate names by comma)
Example: John Doe



Related Content
Articles
Books
The American Psychiatric Publishing Textbook of Psychiatry, 5th Edition > Chapter 40.  >
The American Psychiatric Publishing Textbook of Psychiatry, 6th Edition > Chapter 36.  >
The American Psychiatric Publishing Textbook of Geriatric Psychiatry, 4th Edition > Chapter 33.  >
The American Psychiatric Publishing Textbook of Geriatric Psychiatry, 4th Edition > Chapter 33.  >
Dulcan's Textbook of Child and Adolescent Psychiatry > Chapter 39.  >
Topic Collections
Psychiatric News
PubMed Articles