In Reply: We thank Dr. Lefley for her letter. Between 1979 and 1991 she and her colleagues (1,2,3) developed and documented an exemplary mental health services approach reflecting the organizational cultural competence features that we identified in the literature published between 1994 and 2004—both in our August article and elsewhere (4). The first two of these features involve accounting for community context and cultural characteristics of service populations, which Lefley and colleagues accomplished by deliberately and clearly grounding services in the ecological contexts of their community (including cultural perspectives on mental health and its treatment).
We identified a third broad cultural competence feature, organizational infrastructure, which includes organizational functions such as communication, governance and planning, evaluation, human resources, and service array. Employing communication practices that stressed learning and direct exchanges of information both within the organization and between the organization and the community, Lefley and colleagues facilitated community participation in evaluation, planning, and governance. These efforts, along with a human resources infrastructure that procured culturally competent staff, facilitated a service array responsive to the needs of the population served.
Lefley and colleagues' approach reflected three important characteristics that make up the final organizational cultural competence factor we identified—direct service support. First, the range and capacity of available services reflected the needs of the service population (service availability). Second, policies and procedures facilitated individuals' ability to successfully enter, navigate, and exit needed services and supports (service accessibility). Finally, organizational practices directly promoted service use in the community and facilitated organizational accountability by tracking service use patterns (service utilization).
Lefley and colleagues' approach reflected nearly all of the cultural competence features identified in our literature review and summarized in our organizational cultural competence model. Consistent with the tenets of our model, this culturally competent approach led to service parity in their community.
In her comments on our model, Dr. Lefley underscored that "programs rich in cultural competence cannot persist without adequate funding and zeitgeist support." We wholeheartedly agree. In presenting our model, we argued that its focus on the ability of mental health service organizations to understand and respond to local communities' culturally influenced values, needs, and attitudes toward service emphasizes that cultural competence is an aspect inherent to all mental health services and not only those serving racial and ethnic minority groups. We believe that the dissemination of this important perspective is an integral part of ensuring the zeitgeist that Dr. Lefley highlights as integral to the sustainability of culturally competent services that—like the model she developed with her colleagues—reflect the factors identified in our review.
In the context of mental health services, culture is a dynamic set of factors that have a pervasive influence on the experience of all individuals. As such, recognizing culture and incorporating it into organizational functioning are essential to the development of approaches that lead to service parity. We hope the findings summarized in our model help foster the day when service approaches such as that developed by Lefley and colleagues are the norm rather than the exception.
Lefley HP: Environmental interventions and therapeutic outcome. Hospital and Community Psychiatry 30:341–344, 1979
Lefley HP, Bestman EW: Public-academic linkages for culturally sensitive community mental health. Community Mental Health Journal 27:473–488, 1991
Lefley HP: Cross-cultural training for mental health professionals: effects on the delivery of services. Hospital and Community Psychiatry 35:1227–1229, 1984
Hernandez M, Nesman T, Isaacs M, et al: Examining the Research Base Supporting Culturally-Competent Children's Mental Health Services. Making Children's Mental Health Services Successful series, 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