The Cultural Relevance of Community Support Programs

Recent research has provided insights into the influence of cultural contexts on treatment outcomes for persons with severe mental illnesses. Mexican immigrants have significantly lower rates of psychiatric disorders than Latino and non-Latino individuals born in the U.S. (1). These striking findings suggest that socialization into American culture has noxious effects on mental health outcomes of immigrants. The implication for clinical services is that intrinsic positive resources exist in immigrant cultures that, if not conserved, make individuals vulnerable to psychiatric problems.

A family intervention study found poorer outcomes for Latino patients with schizophrenia, suggesting that highly structured directive interventions represent an "aversive iatrogenic" influence on Latino patients (2). The study raised critical questions about the cultural relevance of different types of rehabilitative interventions and their generalizability to other cultures.

Community support programs are community-based psychosocial rehabilitation interventions that encompass an array of services for persons with serious mental illness (3,4). Services include mental health care, outreach, housing, vocational and educational services, family and community services, and peer support (3,4). Community support programs are guided by the community support system's humanitarian philosophy of care, which was developed by the National Institute of Mental Health (3). According to this view, services should be individualized, empower clients, incorporate natural supports, and focus on strengths; they should be flexible, normalized, accountable, racially and culturally appropriate, and effectively coordinated to ensure continuity of care (4).

Community support programs have been successful in improving community care for persons with severe mental illness; these programs have been shown to be more cost-effective than hospitalization (5,6,7) and more effective than traditional aftercare (8,9,10,11,12,13,14). However, they have been criticized as not supportive of families, of the care families provide, and of families' natural helping networks (15). Although community support programs are mandated to be culturally responsive to ethnic minorities (16), cultural relevance has not been addressed conceptually or empirically in the literature on community support programs, including recent reviews (5,17,18). Moreover, research on community support programs has not specifically examined differential treatment effects for different ethnic groups, and most studies have not provided information about the race or ethnicity of research samples.

A special issue of Psychosocial Rehabilitation Journal on community support programs provided a description of the principle of cultural relevancy. Culturally relevant services should be "racially and culturally appropriate . . . available, accessible, and acceptable to members of racial and ethnic minority groups and women" (4). However, just because ethnic minority clients are increasingly being served by community support programs (19,20,21,22) does not necessarily mean that these services are culturally relevant. Because the humanitarian service philosophy promotes individualized treatment, providers and researchers make the incorrect assumption that cultural factors are taken into account in delivering services to ethnic minorities.

This paper addresses the cultural relevance of services provided by community support programs. Findings from pertinent research and practice literature are discussed in order to derive conceptual and practical strategies that may guide development of culturally relevant programming.

What is cultural relevance?

Criteria for assessing the responsiveness of community-based services are based on their availability, accessibility, acceptability, and appropriateness in meeting the needs of diverse populations (3,23). When services meet linguistic and geographic needs of ethnic minorities and when they are provided by ethnic minority staff (4), it is often assumed that the mandate of cultural relevance is satisfied. Although services must take into account these extrinsic features of an ethnic group if they are to be culturally relevant, cultural relevance is more complex.

A culturally relevant system of care addresses cultural orientations of individuals by understanding and honoring attitudes, values, and behaviors unique to each person as these factors influence service use and outcomes (24). Cultural relevance can be productively viewed as a multidimensional and dynamic process by which the system of care engages in a cultural assessment, encompassing both objective and subjective cultural realities. When the objective is to design and provide services relevant to a particular culture, this process also appraises the fit between the service system and the unique ethnocultural qualities, needs, and expectations of the client system to be served. The client system refers to the client, family, and support network.

Mental health research on ethnic minority groups

Interethnic differences among families dealing with mental illness provide useful insights about cultural influences and resources that should be appraised in the rehabilitative process. Great variation has been found in family practices, conceptions of mental illness, stigma attributed to mental illness, and expectations of the provider system. Generally, ethnic minority families come from collectivistic, sociocentric societies, whereas Western European cultures are characterized as more individualistic. Ethnic cultures are typically centered on the family and supported by extended networks, which generate emotional and instrumental supports for family members in need (25262728).

A multicultural study of family caregiving found that 75 percent of Latino clients and 60 percent of African-American clients lived with their families, compared with 30 percent of Euro-American clients (29). Euro-American families had smaller social networks and relied on professionals for help, whereas minority families had denser and larger social networks and relied on informal networks for help. African-American and Latino families expressed greater hope, optimism, and faith about long-term outcomes of their family member's mental illness. These findings exemplify the caregiving ideology of ethnic cultures, which reflects different adaptive attributions and expectations about the family member's illness and social adjustment (29,30). African-American families showed better adaptive coping through greater tolerance and acceptance in the face of adversity; they had a higher level of self-worth than nonminority families (31).

Ethnic minority families encounter several barriers to their participation in services. Lower socioeconomic status, and in particular lower educational attainment, have been found to be related to inadequate education about illness and lack of familiarity with formal support groups (29,32,33). The stigma attached to mental illness, coupled with minority status, can make family members reluctant to ask for help outside the immediate family, particularly in Indochinese families (32,34). In addition, families' attitudes toward the provider system vary, from African Americans' distrust of professionals, to Latinos' greater deference to professionals, to Asian Americans' reluctance to obtain services (29,30). Poverty, education, stigma, and attitudes shape the interface between an ethnic culture and the culture of interventions that is part of the provider system (35).

A recent study found that African-American and Latino patients with schizophrenia had a more benign symptom profile than their Euro-American counterparts; their symptoms were mediated by higher levels of empathy and social competence (36). Having a prosocial orientation and a range of interpersonal skills can help patients solve problems; sociocentric mechanisms inherent in ethnic cultures may thus give patients an advantage. However, in the course of intensive psychosocial interventions, empathy decreased for patients from minority groups and social competence increased for all groups (37). Such findings stimulate questions about the potential for cultivating sociocentricity and other prosocial cultural qualities that can be incorporated in systems of care. Together these findings suggest that the positive effects of protective cultural mechanisms may be diminished or promoted in the course of treatment, raising the question of whether all treatment components are applicable across cultures.

Practice literature

The practice literature offers several findings that are useful in developing culturally relevant services in community support programs. Among these findings are the cross-cultural applicability of group, family, and peer-oriented approaches; a psychoeducational framework consisting of comprehensive culturally tailored services; and the concept of a culture broker.

Interventions for severely mentally ill persons that incorporate family networks and use group modalities are considered culturally congruent approaches (25,26,38394041424344). The use of groups in the treatment of inner-city minority women was associated with several desirable outcomes, including increased peer support, an expanded social network, and development of crisis management skills (39,40).

International and U.S. studies indicate that the family is a vital resource in the care of persons with long-term mental illness, but this resource is often not tapped (25,27,45). According to DiNicola (46), the idea that family therapy is applicable across cultures is supported by two findings. First, in studies in developing countries, persons with psychiatric conditions who are part of an extended family have better outcomes. Second, in developed countries, culturally driven approaches that stress family and community as treatment contexts have been effective. Sociocentric family practices help ensure the success of family network approaches (25,26,27,28). Network therapy is particularly helpful with Native Americans because it uses the strength of the family collective to treat individual psychiatric problems (42,44).

Plummer (47) described a culturally responsive psychosocial program serving primarily African-American clients in the supportive environment of a clubhouse model that stresses culturally focused staff training. The main modification of the clubhouse model was an empowerment approach emphasizing a diversity-affirming environment, group orientation, and linkages to family and community networks.

Several studies have shown the usefulness of adapting a psychoeducational framework of interventions to the needs of a culture (484950515253). The Community Organization for Patient Access was a program to implement culturally focused services and increase the use of mental health services in a Latino community (50). The program assessed acculturation levels of client-family systems so that treatment and outreach services were individualized. Bilingual-bicultural staff trained in psychoeducational approaches provided a range of therapeutic and recreational services. The program actively included extended family and social networks. Program outcomes included increased use of services, improved attendance, and improved psychosocial adjustment.

Lefley and Bestman (51) reported on a program that used academic and public resources to create a network of neighborhood-based mini-clinics. The program emphasized the need to match a client with a provider from the same ethnic group. Five different ethnic communities were served— African Americans, Bahamians, Cubans, Haitians, and Puerto Ricans. Culture brokers were a distinctive feature of the program. They provided bridging, interpretive, collaborative, and teaching services to clients, the hospital, and the community. Interventions were based on a psychoeducational framework and an active use of the culture broker to facilitate transactions within formal and informal networks. Positive outcomes included patients' increased involvement in the program and fewer visits to emergency services. The positive outcomes were associated with two important features of the program— its unique degree of ethnic matching and the large proportion of ethnic clients served (54).

A six-month intervention for persons with both mental and substance use disorders resulted in similar overall outcomes for minority and nonminority clients, even though the minority clients had lower psychosocial functioning scores at baseline and received less supportive treatment (55). Similarly, Solomon (56) found that African Americans received lower quality care but were more likely to follow through with aftercare.

A study targeting educational needs of ethnic minority participants in vocational training, predominantly African Americans, found that they needed more remedial services because of deficits in math and reading skills (57). The implication for rehabilitation is that these clients may need age-appropriate motivational approaches to counteract possible frustration with educational systems.

Reviewers of demonstration services offered by community support programs for persons with dual diagnoses reported that clients were more likely to be engaged and retained in treatment if they participated in culturally sensitive programming that featured a multipurpose cultural group (21). The group incorporated personal and social components corresponding with ethnocultural themes, needs, and values of African Americans and Latinos.

A family intervention study found that behavioral family management and case management were equally effective among low-income Latino patients with schizophrenia (2). However, at one-year follow-up, participants in behavioral family management had more severe symptoms. Also, several families in the study shifted from low to high expressed emotion, a measure of hostile criticism of or emotional overinvolvement with the patient. The researchers implicated the highly structured program, which involved communication exercises and directives that may have been intrusive and stressful. Conversely, Baker and associates (22) found positive functional outcomes for African Americans participating in an intensive program based on the assertive community treatment model. However, the authors did not indicate how they ascertained the cultural relevance of the program and how relevance was factored into the design and effectiveness of the program.

Collectively these findings point to the complex role of culture and minority status and the need for systems to develop and offer culturally responsive programming.

Conceptual and practical guidelines

Community support programs provide a range of rehabilitative services. Research has supported the effectiveness of some rehabilitation services in meeting the extensive needs of persons from ethnic minority groups who have severe mental illnesses. It is not that the services offered by community support programs are culturally irrelevant. Rather, the issue is whether the values guiding community support programs are being universally applied, because research on community support programs has not consistently addressed the principle of cultural relevance. Because the principle has not been consistently addressed, the issue is whether the underlying Western European values guiding community support programs are being imposed across cultural groups.

For example, the community support system's philosophy equates improvement with greater independence (4). Western cultures value independent action highly (26). However, sociocentric-collectivistic ethnic cultures typically reflect allocentric personality attributes such as interdependence, sociability, family orientation, and concern for others (28,58,59). The attempt to achieve independence and self-sufficiency may conflict with cultural norms and may be countertherapeutic. Applying the values of individualism— independence, self-reliance, rationalism, competitiveness, mastery over one's destiny, autonomous action, and emotional detachment— to persons from sociocentric cultures may not be culturally syntonic. Recent research shows that some approaches based on Western behavioral models may have adverse effects on patients' clinical and functional outcomes (2,37).

Because the normative expectations of one culture should not be uncritically applied to understanding another (60), providers should start from the perspective of clients. A culturally relevant approach involves a combined awareness of and ability to balance the values of the ethnic culture and those of the treatment culture; this approach requires testing cultural and alternative hypotheses (61,62). This approach would help providers discern the potential influence of ethnocultural factors and other possible explanations of behavioral phenomena in the assessment and treatment process.

Two interrelated assessments are needed in designing rehabilitative services and individualizing treatment plans for clients from diverse ethnic groups. The first is a cultural assessment of the client to be served, and the second is an appraisal of how the client fits into the provider culture. A cultural assessment encompasses the client's and family's cultural perceptions of and beliefs about mental illness, their values, and their expectations about the client's social adjustment as well as the family's practices, its supportive social networks, and its attitudes toward and expected relationships with the provider system (63,64).

An assessment of the client's interpersonal and prosocial orientation, which is reflected in the allocentric characteristics of empathy and social competence, can be useful; such qualities can be cultivated and fostered in social skills training and group-centered modalities (36). Assessment of cultural factors can be incorporated into psychosocial assessments, which are ubiquitous in standard mental health practice. Qualitative explorations should be conducted by practitioners knowledgeable about and respectful of cultural differences.

Another strategy is to incorporate a brief instrument to assess social networks, such as the Social Support Questionnaire developed by Sarason and colleagues (65). Such instruments gather information about collectivistic family practices and characteristics and the quality of sociocultural resources that may play an instrumental role in rehabilitation (66). Use of research-based instruments in cross-cultural practice will facilitate assessment, help practitioners integrate research and practice, and ultimately build knowledge about culturally relevant services.

Focus groups can be used to generate culturally specific information from different perspectives— those of clients, family members, professionals, consumer-staff, and community representatives. Such information addresses the fit between the program and the client's culture and informs development of culturally focused programming. Focus group strategies involve qualitative explorations that often yield rich understandings of cultural phenomena and cultural preferences for services as well as opinions about the suitability of treatment modalities (33,676869).

Training staff in ethnographic interviewing will facilitate cultural assessments, as will the use of culture brokers, particularly when staff and brokers share an ethnocultural background with the client group. Information from the cultural assessment, social support measures, and focus groups can help programs identify salient cultural factors, discern the degree of a client's identification with mainstream culture and his or her own ethnic culture, and determine the client's and family's cultural preferences about treatment. Such information will help programs design or coordinate rehabilitative services relevant to the attributes and needs of ethnic minority groups (63,64).

In what ways can programs use knowledge about the various cultural orientations of ethnic minority groups that they serve, including beliefs about mental illness, collectivistic practices, sociocentric interpersonal behaviors, and network supports? A cultural assessment may reveal a high level of collectivism in the client's culture and family and a dense network of social support, combined with a low income and educational level. In this case, the practitioner can develop an individualized service plan that includes group, family, and psychoeducational approaches to foster and cultivate the cultural resources revealed in the assessment, facilitate linkages to entitlement programs, and increase education about the client's illness. A practitioner may be surprised to find that ethnic minority parents will care for an actively psychotic and severely impaired son or daughter, even when entitlement funds provide for board-and-care options.

Because all professionals, including those from ethnic minority groups, have been trained in Western behavioral models, they may unwittingly pathologize or idealize either the minority or the majority culture. On the other hand, when professionals work from the perspective of the client's cultural orientation, they can coordinate services to support values of interdependence, validate sociocentric behaviors, and instill hope, while providing individualized psychoeducational services and respite care.

When cultural assessment of a client reveals a history of collectivistic practices but a current lack of social supports, the practitioner can mobilize program resources to build on the client's sociocentric prosocial behaviors and can target fragmented network linkages. For example, referring the client to a clubhouse with its own collective culture may provide a social context and meaningful roles that are congruent with the client's cultural orientation (70).

Program designers can use information from focus groups to help them understand which program components and services can be made more culturally relevant. With this information they can articulate a framework that guides staff training and organization of services to accommodate sociostructural and ethnocultural characteristics and preferences of the ethnic groups served. For example, programs focusing on housing and independent living skills may find ways to foster community life by incorporating family members, extended networks, and sociocultural activities. Outcome measures for independent living may need to be redefined to incorporate interdependent living skills as culturally optimal. Entitlement programs could be reconfigured to subsidize interdependent living options with supportive family and kinship networks.

Supported employment and educational programs can target the distinct experiences of ethnic minority clients. Programming can focus on socioeconomic and educational deficits and on the combination of stigma associated with mental illness and the outsider experiences of minority status, such as racism and discrimination. A client's perspective should be assessed to discern cultural influences on values and perceptions about work, achievement, success, and goals. These influences may motivate or undermine the client's new roles. Vocational and educational settings should attend to needs and build strengths with cultural programming that offers several types of support.

The work group concept described by Gates and associates (71) offers several strategies that can be culturally adapted. The work group builds on individualized assessments to provide emotional, instrumental, and informational supports. This approach can flexibly integrate cultural perspectives and assist clients in accommodating new roles and settings.

Cultural relevance is an integral value of the community support system's comprehensive philosophy of care (72). The suggestions outlined here are not intended as stand-alone strategies but as practical steps in the development of culturally relevant services. The challenge facing community support programs is the appraisal of culture and the incorporation of its influence in visible and viable ways. Further research is greatly needed to examine the differential effectiveness of rehabilitative services for ethnic minority groups. Qualitative and controlled studies should examine the incorporation of a culturally relevant framework into community support programs serving diverse populations and should evaluate the effectiveness of culturally adapted programs.

Dr. Barrio is assistant professor in the School of Social Work at San Diego State University, 5500 Campanile Drive, San Diego, California 92182-4119 (e-mail, [email protected]).