In today’s progressively global world, professional health and mental health care providers are increasingly required to interact with families whose race, culture, national origin, living circumstances, and family composition are different from their own. This is particularly true in almost any urban clinic in the U.S., but especially so in public contexts, where providers routinely encounter multiethnic and multiracial populations. By the year 2010, immigrant children will comprise 22% of school age children in the U.S. (Connect for Kids, 2006
). In contrast to immigrants from Europe during the 19th century, most families that immigrated to the United States in the last two decades have come from Latin America, the Caribbean, Asia, and Africa (Singer, 2002
). These children and families speak different languages and often have skin color that distinguishes them from the European (majority) culture. According to the National Survey of Children’s Health of 2004, the primary language spoken at home was far more likely not be English in Latino (60%) and Asian/ Pacific Islander (41%) households compared with white (1%) children’s households (Flores & Tomany-Korman, 2008
These populations include families whose notions of mental disorders are totally dissimilar from that of the clinician in charge of making decisions about their care. Mental illnesses (e.g. defined as any current or past year psychiatric disorders that result in functional impairment which substantially interfere with the child’s role or functioning in family, school or community activities) in certain cultures can be largely thought to be completely incurable, or at least unresponsive to modern medical practices (Desjarlais, 1995
; Gureje & Alem, 2000
). In Latin America, deeply rooted cultural beliefs can lead to feelings of guilt and shame, distorted help-seeking patterns, and religious or folk beliefs about the origins of mental disorders (Alarcón, 2003
), ideas reported by immigrants coming to the UK (Cinnirella & Loewenthal, 1999
) and the US (Cauce et al., 2002
). Among some immigrant families, there is a great reluctance or delay in seeking appropriate mental health services, even when health-damaging responses to mental illness can occur (Gureje & Alem, 2000
; Razali, Khan, & Hasanah, 1996
; Whyte, 1991
). Often times, Western medicine is not considered to be the preferred treatment for mental disorders in these countries (Alem, Jacobsson, Araya, Kebede, & Kullgren, 1999
; Saeed, Gater, Hussain, & Mubbashar, 2000
Moreover, ethnic and racial minority families from the US may also differ in their explanations about mental illness and treatment (Novins et al., 1997
), sometimes based on the types of services they historically had available and not necessarily due to an alternative conception of illness causation (Kirmayer, Groleau, Guzder, Blake, & Jarvis, 2003
). For example, African American and Native American families may have alternative explanations of mental illness such as supernatural or spiritual forces that lead youth to undesirable behaviors (Cheung & Snowden, 1990
). Ideas of coping with mental illness may also vary, with African American youth sometimes being encouraged to use will power to “tough out” situations (Browman, 1996
) or Asian American youth being advised to not dwell on uncomfortable thoughts (Cheng, Leong, & Geist, 1993
We know that disorder, disease, and healing may manifest differently in different cultures
(Kleinman, Eisenberg, & Good, 2006
). The decision to use medications (Snowden & Yamada, 2004
) and help-seeking behaviors (Snowden & Yamada, 2004
) are partly driven by culture. We also know that some children can be misdiagnosed because screening instruments and diagnostic criteria are often developed by (and for) the majority culture; that is, the culture of the majority of providers and health systems, not necessarily of the majority of the population in many communities (Dressler & Badger, 1985
; Huang, Chung, Kroenke, Delucchi, & Spitzer, 2006
; Vega & Rumbaut, 1991
). These facts suggest that cultural differences may play a critical role in the individual’s recognition of mental illness and the provider’s detection of the mental illness including the perception and intensity of stigma associated with mental health help-seeking behavior and the understanding of what might be considered mental health disorder requiring appropriate mental health services.
Multicultural groups are diverse not only in their beliefs and expectations, but also in their assumptions about what the clinician can do for them (Katz & Alegría, 2009
). Individuals seeking help may possess diverse views of what matters most to them as compared to the provider, which may result in a lack of shared problem definition between the individual and the provider (Suurmond & Seeleman, 2006
), increasing the potential for misaligned treatment approaches.
Similarly, changing family structures and the diverse context of childrearing may be challenging for clinicians whose personal experience with family and neighborhood is very different from those of their diverse multicultural clients (Burkard, Ponterotto, Reynolds, & Alfonso, 1999
). Children and youth today live in varied family arrangements and contextual environments, each with its own distinct cultural milieu. For example, 26 percent of US children in 2000 resided in single-parent households and 15 percent lived in blended families (Kreider & Fields, 2005
), signaling a significant shift in the living arrangements of children since the 1970s. Children live in the context of their families -- even those who are in foster care, institutionalized, or otherwise physically separated from their original families -- and their communities. For too many this context also includes involvement with child welfare and the juvenile justice system (Freudenberg & Ruglis, 2007
; Lauritsen, 2005
). Consequently, the context in which these families live, and even the definition of families, has been dramatically altered in the last three decades.
Yet, the context of childrearing has a profound impact on well being and risk for illness. A child’s resilience is dependent upon numerous contextual factors, not the least of which includes a reliable and supportive adult who cares about them (Cicchetti & Rizley, 2006
; Oades-Sese & Esquivel, 2006
). There is noteworthy cross-cultural work (Draper & Harpending, 1982
) suggesting that children might be particularly reactive and susceptible to the context of early childrearing that is closely linked to their living arrangements. Childrearing differences also appear to influence the child’s prospective bonding and psychological development. The development of optimal behavioral strategies, thus, appears dependent on the social and physical environmental cues that regulate interpersonal and behavioral development (Belsky, Steinberg, & Draper, 1991
) in these contexts. These cues vary by the childrearing patterns occurring in different family arrangements.
Because children spend a significant portion of time outside their homes, neighborhoods and schools also play a critical role in their mental health outcomes. Furstenberg’s ethnographic studies (Furstenberg & Hughes, 1997
) pinpointed how families living in high-risk neighborhoods might select strategies of childrearing (i.e. protection and insulation from risk) that differ from those living in low-risk neighborhoods, constraining opportunities for social interaction and increasing isolation from peers and socialization activities. Environments in which ethnic and racial minority children live are characterized by residential segregation (Logan, Stults, & Farley, 2004
), poor quality housing (Simmons, 2001
), limited resources, exposure to violence (Jaycox et al., 2002
) and fewer institutional and community support systems (Hoberman, 1992
). There is evidence showing how neighborhood safety relates to risk for mental illness (Alegria, Sribney, Woo, Torres, & Guarnaccia, 2007
) and how neighborhood socioeconomic conditions correlate with suicide rates, violence, adolescent well-being, and behavioral and emotional problems in children and youth (Baker & Taylor, 1997
; Ferrada-Noli, 1997
; Furstenberg & Hughes, 1997
; Sampson, Raudenbush, & Earls, 1997
). The work of Sampson and colleagues (1997)
underscores how the ability of adults in the neighborhood to regulate social behavior, as evidenced by high levels of collective efficacy, is associated with neighborhood levels of violence and personal victimization. These data underscore the importance of the neighborhood environment to children’s mental health. For clinicians serving diverse children and youth populations in marginalized and segregated communities, understanding neighborhood conditions and community supports may be paramount. A better understanding of the context of childrens’ and families’ lives may allow them to identify what precipitates a child’s negative behaviors and increases their chances of developing mental illness.
In addition to living in neighborhoods with high levels of environmental stress, ethnic and racial minority youth are disproportionally more likely to have interactions with the juvenile justice system (Freudenberg & Ruglis, 2007
; Lauritsen, 2005
), or to have relatives involved in the criminal justice system as compared to their white peers. As a consequence, these minority youth may expect greater injustice from formal institutions (Woolard, Cleary, Harvell, & Chen, 2008
). Persistent exposure to discrimination and racial profiling (Rousseau et al., 2009
) can also impact their ability to trust and collaborate with mental health providers. Community, religious, and social agencies are therefore more typically trusted as resources to confront the hardships and stressors associated with their own and/or their family’s living circumstances (Alegria et al., 2002
). Expectations of misunderstanding and/or coercion within traditional institutional services (e.g. schools, police, and government services) tend to discourage minority youth and families from seeking professional mental health care (Takeuchi, Bui, & Kim, 1993
). As a result, there is a larger gap between the mental health service system’s offerings in contrast to the negative expectations and unmet needs of diverse children and youth.
Relying on a traditional clinical approach, the mental health system is often ill prepared to serve a diverse clientele. Differences in culture, language, family composition, living arrangements, and neighborhoods lead multicultural youth and their families to have different expectations of clinical services. Mental health systems must now meet the needs of children (Williams & Collins, 2001
) that are very distinct from those that the system was developed to serve. Unfortunately, traditional practice models appear unresponsive to the special needs and the most pressing concerns of multicultural youth and their families. This may leave them without care, or it may cause them to prematurely drop out of care.
A Failing Children-Adolescent Mental Health Service System
While children on average are often underserved by mental health care in the United States, ethnic and racial minority children receive an average of half as many counseling sessions (Pumariega, Glover, Holzer, & Nguyen, 1998
) than their white counterparts. As compared to non-Latino whites, both Latino and African-American youth exhibit lower rates of mental health service use (Kataoka, Zhang, & Wells, 2002
; Yeh, McCabe, Hough, Dupuis, & Hazen, 2003
), make fewer office visits for treating their attention deficit hyperactivity disorder (ADHD) and depression (Olfson, Gameroff, Marcus, & Jensen, 2003
; Olfson, Gameroff, Marcus, & Waslick, 2003
), and enter care later. Ethnic and racial minority youth are also less likely to receive multimodality treatments for their ADHD (Bussing, Schoenberg, & Perwien, 1998
) or formal services for their suicide attempts (Freedenthal, 2007
), in contrast to their white counterparts. Thus, the evidence suggests that the mental health system is failing many minority children and families as indicated by low rates of entry into care, high rates of drop out, and greater rates of unmet need for mental health services. As described above, one potential explanation for the system’s failure might be the inattention paid to the culture, context and diversity of multicultural children and families.
The Role of Culture and Context: Why it Matters
Culture, in its simplest definition, is a set of shared understandings, a view of “how we do things around here” (Glisson & James, 2002
; Hofstede, 1998
) that is socially constructed and evolving. Those who write about culture refer to it as “contextual, emergent, improvisational, transformational, and political (Laird, 1998
),” so that a group's cultural identity can evolve over time or in reaction to the environment or retrench toward some core values, given certain stresses. As such, it exists at all levels in a society – individuals come from a “cultural milieu” that they carry with them. As they join together with others (in communities, schools, or organizations), a shared set of beliefs and understanding emerges. As this suggests, culture is always dynamic and emergent in social interactions. When cultural elements (i.e., beliefs, values, routines) align across levels (e.g. family, peers, neighborhood), it is almost invisible. In this scenario, cultural competence is rarely an issue. However, in our multi-cultural, complex society, with a host of “cross-cutting parameters,” culture is often visible – in different assumptions, ways of interacting, values, and goals. It is this complexity of people attempting to survive and thrive in multiple cultures that makes current concepts of “cultural competence” and “diversity” essential to the delivery of culturally relevant and effective mental health treatment (Bigby & Perez-Stable, 2004
). For the clinician who has innate biases and assumptions about behavior and child development given the mainstream culture becoming “culturally competent” to an evolving and dynamic culture of diverse patients becomes a challenge, possibly a myth (Dean, 2001
). Acquiring awareness of these biases, developing cultural humility and reflection, and attempting to address these biases is a process that proceeds in stages, so that being culturally "naive" is not a fault but a starting place.
At its most basic level, “mental health” is a cultural construct – our society has, via cultural agents (i.e., psychiatrists, psychologists, DSM-IV, legal system), defined mental health and mental illness in a way that corresponds to our underlying Western-majority culture. Our society has a long-standing and uneasy cultural view of where the boundaries of mental illness should lie – e.g., the “bad vs. mad” distinction has long been debated. Hence, even the focus of mental health treatment, itself, is NOT self-evident – rather what’s seen as “normal” is shaped by views, assumptions, and orientations that are, at their core, cultural judgments (Erikson, 1966
; Goffman, 1963
Therefore, it is not surprising that when a complex and diverse society, such as ours, faces these essential questions of acceptable vs. unacceptable behavior, treatment vs. punishment, then the underlying cultures of the different stakeholders may not be completely in sync with these definitions. It is also not surprising that as people become more involved in the mental health “system,” they find the “sticking points” where their cultural beliefs do not completely map with prevailing paradigms and where, as diverse families interact, they develop new awareness and understandings. In short, they develop a culture that explicitly incorporates views of mental health, treatment, clinician roles, etc. However, as with any culture, this developed culture builds from what already exists (in participating individuals, families, communities, organizations) to become a newly created culture shared by the participants and enacted within the clinical encounter. Whether this emerging culture feels comfortable, hostile, hierarchical, etc. must be negotiated (often without explicit recognition of the process) by the involved stakeholders over time. For a new multicultural family coming to mental health care, rarely does this negotiation ensue, leading to misunderstanding and potential drop out (Singh, McKay, & Singh, 1999
Discussions about culture or diversity revolve around these essential dynamic and multi-faceted processes of developing norms, beliefs, routines, and expectations that are shared between the family/youth and the provider. We often take the “short-hand” approach by thinking in terms of easily observed or known differences among people – skin color, language, where they (or their families) came from, SES, etc. But this is simply a convenient way to make sense of the much broader range of factors that influence perspectives, roles, understandings, values, etc. (i.e., culture). In the following sections, we think beyond these “easy” identifiers to begin tackling the difficult and pervasive ways in which culture influences (and is influenced by) the diversity of youth and families in subtle ways. Comprehending their experiences, situations, and organizations allows for a more holistic understanding about how culture may be useful in improving quality and processes in the mental health system for both the youth and their families. At the same time, the family/youth is scanning for cues (both in behavior and interaction) to evaluate if the provider really understands what matters more to them. Therefore, understanding culture is an interactive process that requires being open to learning about others as an ongoing process in both the family/youth and the provider.
Although most mental health treatments in urban clinics tend to be cross-cultural, providers vary tremendously in the extent to which, and manner in which, they address ethnic/racial and cultural differences in the clinical encounter (Maxie, Arnold, & Stephenson, 2006
). Cultural values also include expectations about age, gender, and family dynamics, as well as beliefs about health and health care (Geertz, 1973
); all potentially affecting decisions made during mental health care. A patient’s ethnicity/race/culture may impact what s/he reports, what the clinician asks her/him to report, and how the clinician interprets the information provided (Burgess, Fu, & van Ryan, 2004
). “A cultural open perspective, therefore, can help clinicians and researchers become aware of their hidden assumptions, biases, stereotypes and limitations of current practice and can help them identify new approaches appropriate for treating the increasingly diverse populations seen in psychiatric services around the world”(Kirmayer & Minas, 2000
Thinking of Culture at the Individual Level
Culture, by definition, is not
an individual construct but is developed interactively and is contextually defined. Individuals are embedded in a cultural milieu. Culture is formed from a dynamic combination of ascribed characteristics (e.g., race, sex, country of origin), achieved characteristics (e.g., education, gender, social position), and experiences (e.g., discrimination, hierarchies, success). Concepts of “cross-cutting parameters”(Blau, 1974
) and “correlated constraints” (Magnusson & Cairns, 1996
) both seem relevant here. The former suggests that each individual is basically a Venn diagram of unique and overlapping components – recognizing each of these provides points for understanding individuality and for creating common linkages between/among diverse individuals. The latter suggests that each of these parameters does not operate separately – rather changes in one domain and has implications for expression/opportunities of other domains (Farmer & Farmer, 2001
; Farmer, Farmer, Estell, & Hutchins, 2007
). There is also evidence that there are cultural determinants to our neurocognitive capacities to assess problems and formulate solutions (Hedden, Ketay, Aron, Rose Markus, & Gabrieli, 2008
; Nisbett & Masuda, 2003
There can be several primary implications of this. Culture is complex and continuously emerging (dialectic of process is critical here). Adequate understanding of an individual’s core beliefs, approaches to life, goals, etc. are likely to be more relevant than simple demographic categorizations. Yet, the most easily observed characteristics of an individual (e.g., race, sex, and age) may or may not be the most salient for understanding that person’s culture in the clinical encounter.
Thinking of Culture at the Family Level
Families are central to the cross-generational conveyance of culture. Families also actively create their own culture (through both omission and commission). Understanding HOW a family works (expectations for behavior, values, norms, goals, etc) IS an assessment of culture. Again, cross-cutting parameters are important here. How much a given individual within a family adheres to/subscribes to the dominant family culture is critical to understanding family dynamics. The “past is never past” – what used to be (either in this current family configuration or in members’ families of origin) influences how current events are processed and integrated into the whole.
Assessing fit between family’s culture and treatment culture is also essential (e.g., should problems be discussed? Should all family members have a say in decisions or should certain members make decisions and others follow? Is violence “normal”?). The child in therapy has a vast number of cultural and contextual influences on his or her ability to rebound and get better. The therapist who is sensitive to the culture of the child and family still cannot fully know the complexity of these influences on any given child. The therapists’ ability to help a child get better is highly dependent upon many other factors and can be made better by his or her full engagement of the family. The 2003 Final Report of President’s New Freedom Commission
, following an intensive investigation in the nation’s mental health system, declared that treatment must be consumer and family driven. The National Federation conducted an intensive process to develop a working understanding of what it would mean to be family-driven. That definition says that families have a primary decision making role in the care of their own children as well as the policies and procedures governing care for all children in their community, state, tribe, territory and nation
(National Federation of Families for Children’s Mental Health, 2008
). The therapist who engages the family in decision making will be better able to provide therapy that appropriately responds to a child’s culture and context.
The primary implications of this are that there’s been a tremendous amount of effort/interest in family-centered treatments. However, it seems fairly rare that providers actually seek a full understanding of a family’s current “culture” by examining roles, expectations, goals, “fit,” etc. The way a family experiences treatment, and wants to be involved in treatment are contingent upon the family’s culture; yet this fundamental dynamic of the family is rarely assessed (López & Hernandez, 1987
). Recognizing the culture of the family and working to actively examine points of correspondence and difference from the culture of treatment is an essential part of quality treatment. Not all families need to participate in treatment in the same way and not all treatment needs to be conducted the same way across families.
Thinking of Culture at the Organizational Level
There has been a great deal of attention to the role of organizational culture in mental health treatment (e.g. Glisson’s work and its off-shoots, particularly Glisson & Green, 2006
; Glisson & Hemmelgarn, 1998
; Glisson & James, 2002
; Glisson & Schoenwald, 2005
). This literature suggests the importance of recognizing the organizational culture for how treatment will be provided, whether evidence-based interventions are likely to be conducted, and their desired outcomes. Specifically, Glisson and Green (2006)
have found that children attended by child welfare and juvenile justice case management units with constructive organizational cultures (those whose organizational norms and expectations promote that case managers be mutually supportive, expand their individual abilities, and preserve positive interpersonal relationships) were more likely to access needed mental health care. Glisson and James (2002)
also demonstrated how constructive cultures in case management teams had a greater impact than climate on decreasing staff turnover, augmenting job satisfaction, and enhancing service quality.
Beyond these “usual” conceptualizations of organizational culture, it seems important to examine clinical policies, supervisory practices, referral practices, and linkages to the community as indicators of the organizational culture. To what extent does the way in which work is done in an organization reveal the organizational culture and influence the recognition of culture at other levels? In addition, there seems to be more attention to organizational culture as an entity that is shaped by and affects employees than as a dynamic process that is relevant to and influenced by the interplay of these employees and families/youth they work with.
The work of Glisson and Hemmelgarn (1998)
alludes to how youth’s positive service outcomes greatly rely on the case manager’s attention to each child’s distinct needs, the caseworkers’ responses to unanticipated problems brought by the family, and their persistence in traversing bureaucratic obstacles to attain needed services. But as Ware et al. (2000)
so clearly describe, certain aspects of the organizational culture, like accountability, can increase the amount of paperwork required and consequently decrease clinical time to engage with the family/patient and negatively affect the ability to focus on the child’s unique needs and respond to unexpected family challenges. So there is a strong interaction between how the organizational culture impacts the culture of providers and how, in response, this influences patient outcomes. An additional example is provided by Becker and Roblin’s study (2008)
showing a positive association between primary care practice climate and patients’ trust in their primary care physicians, which also influenced greater patient activation. So practitioners and staff who described having more favorable practice climates (characterized by team orientation, task delegation, role collaboration, patient familiarity, and autonomy) had higher trust in their primary care practitioners, and these patients demonstrated higher patient activation.
But there are also ways in which the organizational culture negatively impacts patients. For example, it is very common in conversations and documentation in mental health facilities, to refer to “Mom” (i.e., “Mom has a new boyfriend,” “Mom just started a new job,” etc). This somewhat innocuous language seems a serious violation of understanding both individual and family culture and recognizing families and individuals as unique (“Mom” as a proper noun is only appropriate in our culture to be used by a woman’s offspring or others who view her as playing a “mothering” role in their lives). It is not used as a name for unrelated adult women (except in mental health settings). To do so suggests either (a) a familiarity that is inappropriate, or (b) a stereotype of the role that can be used as short-hand to describe the “typical” mother of a child with mental health problems. Either of these suggests an organizational culture that devalues families and individuals and resorts to simplistic categorizations to understand the needs, expectations and likely behavior of others.
The primary implications of this is that organizational culture is a “deep” or “meta” construct that characterizes an organization (Hofstede, 1998
; Rousseau, 1990
). Previous work suggests that it is important for explaining the way in which work is conducted, as well as the likelihood of innovation being accepted. More formal attention should be given to the ways in which organizational culture mirrors, supports, and diminishes the role of these diverse families’ cultures at other levels. Changes in apparently “small’ ways may create significant shifts in organizational culture and treatment (e.g., from the above example, requiring that children’s mothers always be referred to by their name, rather than the generic “Mom”). Organizational culture appears to be more dynamic than it is often portrayed – recognizing the key individuals, relationships, factors that create “culture shifts” could be critical for understanding organizations, treatment, provider-patient relationships, and service outcomes.
Thinking about Culture at the Community/Society Level
Since the mid 1970s, many people have discussed the importance of “nesting,” of an “ecological perspective.” Bronfenbrenner’s work (1997)
is frequently cited but rarely taken seriously. All other levels of society are influenced by the broader community/ society – whether as a base for the smaller unit’s culture or in active contradiction/rebellion against it. For many individuals, families, and even organizations, the local community IS as “macro” as it gets. Adoption of expectations, norms, values, goals, traditions, from a relatively small physical region is typical for most people. Most people, including mental health providers, have a difficult time truly understanding cultures that are far from their own experiences. This doesn’t refer to just “foreign” or “distant” cultures, but seems particularly relevant for understanding subcultures and individuals within the same overarching culture (e.g., truly grasping what it would be like to live in a culture very different from one’s own experience. For example, where education isn’t valued for girls, where intra-family violence is “normal,” where women work, where college attendance is expected, where evidence-based treatments are common, etc.). It’s much easier to make general statements about cultural differences and to then superimpose this additional dimension on one’s own cultural understanding, than it is to truly grapple with what it means (at all levels) to be of a different culture.
Like individuals, families, and organizations, culture is a dynamic process in communities. Given the natural inertia of large entities, culture is probably less changeable at this level. However, it is critical to recognize this process of sociopolitical change. It is also important to recognize “enacted culture” as well as espoused culture (e.g., for the “takes a village…” example, this is a popular statement of cultural values. However, when no one volunteers for mentoring, respite, etc., it suggests that the actual cultural values may be substantially different than the voiced ones). Sub-cultures are a critical element of community/societal culture. As with other levels, the cross-cutting parameters that define these, both by isolating and connecting are critical.
The primary implications of this are that cultural and contextual sensitivity and awareness seem essential for recognizing diversity. However, these factors are unlikely to result in mental health professionals breaking completely free from their own culture and context to truly understand and experience the world of diverse children and families through a different cultural lens. Rather, they should be helpful for recognizing the mental health provider’s own assumptions, expectations, norms, biases etc. and to open the door to exploring how these correspond to those of “others” – that is their patients and families. Examining enacted culture (i.e., actual behavior) in their diverse patients may be a better indicator of core beliefs, norms, etc. than getting reports of expressed culture. Societal culture is experienced by these families and youths through the filters of the “closer” levels (e.g., organizations, family). Therefore, as with the other levels, this makes it inappropriate to assume one’s culture based on observable or knowable characteristics. Rather, cultural considerations must be one of the driving forces in improving services for diverse children and youth and cultural ways of healing should be honored, supported and funded. This might require a paradigmatic shift in how we approach and offer mental health care that seriously considers diversity, culture and context.
In order to achieve cultural awareness, understanding, and respect, we propose the following:
- the adoption of a public health model with integration of prevention and intervention efforts as the first line of “treatment”
- the development of community/family partnerships that can help realign the mental health services to the needs of these diverse children and families; and
- a change in organizational culture.