reflection

One Size Does Not Fit All: Taking Diversity, Culture and Context Seriously

Margarita Alegria, Ph. D.,* Marc Atkins, Ph.D., Elizabeth Farmer, Ph.D., Elaine Slaton, R.N., M.S.A, and Wayne Stelk,

Ph.D.

Introduction

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.

Go to:

How do we accomplish this Paradigmatic Shift?

The foregoing analysis demonstrates that distinct worldviews, shaped by culture, exist at the level of the

individual, family, neighborhood, and clinic. The worldview of the youth and family may not fit the cultural

assumptions of Western mental health treatment. On the other hand, the worldview of the treating clinician may

bias assessments toward “pathologizing” thoughts, emotions, and behaviors that are common to a particular

culture. Because these cultural disparities inevitably lead to ineffective treatment, it is incumbent on clinicians

and clinics to recognize the way in which their cultural insensitivities are expressed in clinical practices and

organizational policies. A paradigm shift is needed through which clinicians and the institutions that support

clinicians come to the fundamental recognition that understanding of one’s culture is vitally important to

treatment success and that each participant in the treatment process has a unique worldview that is shaped by

each participant’s personal culture. The remainder of this paper will focus upon various strategies to achieve

this paradigm shift within the mental health system toward greater accommodation of culture as a fundamental

aspect of mental health services.

A Public Health Model as a Way to Take Diversity, Culture and Context Seriously

Despite a long-standing call for a public health framework for children’s mental health services

(Bronfenbrenner, 1997; Institute of Medicine, 1994, 2009), there has been little progress towards this goal and

no infrastructure to support universal prevention programs for mental health. Instead, prevention programs are

most commonly tangential to the goals of the contexts in which they are implemented, such as social emotional

programming in schools, or mental health diagnosis and treatment in primary care, with uneven effects and poor

sustainability. As an alternative to the current system of mental health services, we suggest that a public health

framework would promote children’s adaptive functioning within key ecological contexts, enhancing

sustainable setting-specific goals and processes in the communities where these diverse youth live

The major implication of integrating mental health goals into the ongoing tasks of key natural settings is to

acknowledge the diversity related to the range of persons and contexts important to children’s development.

Acknowledging the importance of key ecological contexts to children’s development would encourage an

alignment of mental health research, programs, and resources to the key predictors that promote successful

adaptation in that setting, including an appreciation for cultural norms and values endemic to each setting. To

that end, change emanates from within the context and it is the form or structure of contexts that would guide

services (Frazier, Cappella, & Atkins, 2007). A second implication of aligning mental health services to

accommodate natural contexts is the identification and support of indigenous resources within these contexts

who can serve as agents of change. This follows logically from the prioritizing of setting goals and is important

both to ensure the sustainability of program goals and processes as well as to integrate the norms and values of

key members of the setting.

Development of Community/Family Partnerships to Realign Mental Health Services

Community-based interventions have shown promise across a range of illnesses and populations (Borg,

2002; Schooler, Farquhar, Fortmann, & Flora, 1997; Sorensen, 1998; Wagner et al., 2000), since conventional

research and dissemination approaches to mental health care delivery have not resolved mental health problems

among ethnic and racial minorities. This may be partly because these approaches may not respond effectively to

the needs and life circumstances of these populations. Many of the risk factors (or antecedents) of disruptive

and behavioral problems are associated with disadvantage and misfortune (Frick & Kimonis, 2005). Living in a

socially and economically depressed community plagued by joblessness and crime, being part of a home which

lacks adequate resources, and having friends who practice risky behaviors like engaging in gang activity, are all

risk factors for subsequent mental health problems that are embedded in the community. In order to overcome

such risk factors, it is suggested that young people gain exposure to individuals and groups who espouse

protective values and upon whose behavior they can model their own. A first step is to develop

community/family partnerships that investigate with community members which types of family and youth

supports would prevent community patterns leading to disruptive or problem behaviors of children in those

communities as well as distinguish individuals and groups who promote protective values. Social and

institutional supports occur best in the context of social supports, relationships and inclusion within the

community. Participation and partnership with community agencies may be a vital way to generate youth

inclusion and alternative supports that can facilitate preventive mental health and substance abuse treatment in

settings outside specialty clinics.

This community-family partnership also requires increasing parents’ political involvement in the design and

implementation of collaborative mental health system enhancements that focus on the community system, and

not on one particular child. Part of the effort would be to identify ways to maximize the mental health

promoting capabilities of communities. The emphasis is on obtaining a deeper understanding of multiple factors

and system patterns leading to disruptive or problem behaviors in children within their particular community

context. Using this information, community agencies in alliance with mental health providers and families can

establish empirically based strategies that are community centered and strength-based to reduce these disruptive

youth behaviors.

Changing Organizational Culture in Mental Health Systems of Care

It is our nature as humans that we do not become aware of a constant until we experience a difference. For

people who are raised in a racially homogeneous culture, there may be little awareness of the profound impact

that culture has on a person’s worldview. In order for a provider organization to become fully respectful and

responsive to clients of other cultures in a broad sense, administrative and clinical managers must understand

the cultural values inherent in a clinic’s intake, assessment, and treatment methods. Once they are cognizant of

these values, clinic managers should make every effort to alter practices to be more culturally responsive to

diverse value sets. Where practices cannot be easily adapted for other cultures, providers should at least

appreciate the challenges of “fit” between the families’ culturally-based worldview and that of the treatment

milieu. To the extent possible, families and youth should be asked about their preferences. If the client’s

preferred treatment approach is not available, the treating clinician should solicit feedback from a cultural

liaison (Kirmayer et al., 2003) throughout the course of treatment regarding how the recommended treatments

can be adapted to the client’s cultural preferences.

Provider organizations, such as community mental health centers, need to actively plan to become more

responsive to their client’s culture. All employees and associates of a provider organization must have an

awareness of the impact of culture on treatment outcomes. This awareness of culture should be reflected in all

provider policies and practices related to client engagement and inclusion, needs assessment, case formulation,

goal context, treatment intervention, and treatment location. Provider managers should understand that

improved cultural awareness does not happen with a simple message to staff that it should happen. This

message must be accompanied by structural changes (policies, client engagement strategies, linkages to

culturally-based community resources, a diversity advisory committee), as well as operational changes (clinical

interventions that are sensitive to other worldviews and patterns of communication among family members).

Such structural and operational changes are best accomplished when internal staff and external advisor-

stakeholders cooperate to develop explicit work plans that are reviewed by management, and are celebrated by

both the organization and the community.

We propose a set of suggestions for how the collective community of interested individuals wanting to reform

children’s mental health services might respond to the proposed paradigmatic shift.

Recommendations for Research

We will need to identify what it would take to build a new science base of community interventions research

that takes into account the culture (refers to the broad, historically-based sets of traditions, mores, folklore,

interactional patterns, and values of the ethnocultural group) and local context (refers to the immediate

expression of culture in community institutions and community life more generally), so that community mental

health interventions are suited to the real-life circumstances facing diverse youth and their families. As a result,

a new science of community intervention research within a public health model needs to be developed and

tested. This type of community intervention would focus on how to enhance community impact and resource

development, and how to measure community impact over and above the diverse youth’s outcomes. This

research would, as part of a public health model, consider a youth’s resilience as stemming from maintaining a

cultural anchor, mirroring not only innate qualities of the child and his/her culture, but also the capacity of the

child’s environments to provide access to mental health enhancing resources. The implications of this research

approach are that we might start attending to cultural context as the focus of community mental health

interventions, emphasizing interventions that address local community structures, norms, and resources to

enhance community life of diverse youth and families, rather than addressing the individual difficulties of the

youth. We would need to test whether these types of interventions close the gap between knowledge

development and knowledge use in the community for improving the mental health of these diverse youth.

To assist in the implementation, we will need to explore models of multi-level community interventions that can

be developed in partnership with families and practitioners, so as to integrate local cultural context in the

conceptualization, implementation and outcome assessment of these interventions. Rather than beginning with

specific community interventions, even if evidence-based, we may also need to delve into the value of tailoring

community interventions on the basis of what families want and direct them on the development of local

resources as an overarching intervention goal. We need to be able to answer what kinds of cultural

considerations need to be adhered to in order to assess the relevance of community based interventions across

cultures and local contexts. We would also need to test the effects of participation and partnerships on public

health interventions and mental health outcomes to evaluate their contribution.

Recommendations for Providers

Child-adolescent service providers need to improve their own awareness of the importance of cultural

differences as a factor that affects treatment outcomes. This will entail making providers mindful that as

members of a dominant and different culture they can inadvertently be part of the power dynamics that shape

the reality of smaller communities. It is therefore very important for providers to be cognizant of how different

communities are, and not take their views and values for granted. Providers may also need to become conscious

of their complicity in reproducing power dynamics within their professional culture. For example, social

competence (Odom, McConnell, & McEvoy, 1992) judged to be inappropriate by a teacher, might be the only

available behavioral option for certain youth in a setting that lacks personnel trained to conduct linguistically

and culturally relevant instruction and remediation. Mental health providers may be unaware of the persistent

inequities that characterize the educational experiences offered to non-Anglo students, and the paucity of ethnic

training in teacher preparation programs (Figueroa, Fradd, & Correa, 1989). It is in this real world intersection

that educators, researchers, parents and mental health providers must collaborate to develop service delivery

models that help improve academic and mental health outcomes for these diverse children.

Similarly it is critical for providers to accurately and validly capture the views of diverse cultural groups when

assessing mental health. This may require offering providers cultural liaisons (Kirmayer et al., 2003) or

community aids (Katz & Shotter, 1996) that can assist them in recognizing the significant role of culture,

language, ethnicity, and local context in how diverse families prioritize, respond to and adhere to mental health

treatments. A new approach to training providers would promote identifying social support and other contextual

protective factors in the mental health of these diverse children that can be targeted by interventions. One

potential venue might be expanding school-based mental health systems to enable community interventions that

combine resources and perspectives from schools, parents, community liaisons, and mental health agencies to

link underserved children to mental health services (U.S. Surgeon General, 2001; Weist & Schlitt, 1998).

To implement such advances might involve forming interagency coalitions and/or supporting learning

collaboratives (Wenger, McDermott, & Snyder, 2007) of parents, community leaders, teachers and school-

based mental health workers that facilitate mutual learning and communication mechanisms among these

groups. It might also entail conducting needs assessments to understand the linguistic, cultural, organizational,

and regulatory barriers faced by these diverse families in achieving access to mental health enhancing resources

in their communities. Also under consideration might be the establishment of clinical assistance teams and

technological systems and processes (e.g., school-based data management and web-based telecommunication)

for information sharing and mental health consultation to community agencies. Furthermore, it might include

developing tools that facilitate linking diverse families to community and state resources as well as linking

providers to trainings for intervention development and consultation regarding mental health service delivery

for these families.

Recommendations for Policymakers

Provider organizations cannot become more culturally responsive without supplemental resources and technical

assistance at the federal, state, and local levels. It is difficult for provider organizations to become more

culturally responsive without guidance and technical support from governmental agencies and private resources

that have experience in the process of organizational change. Achieving a greater cultural awareness for the

provider and the organization requires explicit planning and resources, as well as staff training and increased

supervision. These indirect costs are not typically included in fee schedules for service payment and could be

restructured as part of the payment structure. Federal, state, and private insurance payers must incorporate these

indirect costs into their fee schedules; or find other mechanisms to pay for the expense of change, such as

technical assistance centers that offer training and support without cost to the provider organization, and without

passing these additional “costs” to already overburdened providers. To implement such a recommendation

necessitates convening a working group of school personnel, investigators, policy makers and legislators for

exploring funding and reimbursement mechanisms for some of the needed organizational and provider changes.

Recommendations for Consumers

Activating and training youth and caregivers on the importance of sharing with providers not only their mental

health problems, but also information linked to their core beliefs, approaches to life, goals and expectation of

treatments is vital. Emphasizing to youth and caregivers the importance of helping providers understand the

youth’s daily activities, peer relationships and family dynamics is indispensable so that the clinician does not

have to use their preconceived notions. This can help contextualize the differences in the family’s circumstances

so that the provider makes fewer mistaken assumptions. Currently, consumers are likely to face linguistic and

cultural distance with their mental health providers due to a shortage of bilingual and bicultural staff (Malgady

& Zayas, 2001).As a result, biases may interfere with both the diagnostic and intervention processes leading to

misinterpretation (Malgady & Zayas, 2001) and poor treatment outcomes.

Also necessary may be the development of a mental health literacy training program for caregivers of diverse

youth suffering from mental health problems that can improve recognition and overcome service use barriers.

The purpose of this training would be to improve the capacity of community based agencies to engage with

diverse families, particularly those unacculturated to the US and with limited language capacity regarding

mental health awareness, management and treatment resources and options. To aid in the development of such

literacy training may require collecting information from community agencies and mental health workers to

inform the training and solicit community and expert input in the design and piloting of the literacy training

program.

Go to:

Conclusion

There is no question that major changes are required to develop and implement mental health services that

better match diverse families’ unique needs. We recognize that these changes require bold public health

approaches and novel ways of bridging community/family partnerships to mental healthcare system constraints

(Alegría, Canino, & Pescosolido, 2009). More importantly, however, they require the cultural and contextual

tailoring necessary to bridge the quality chasm confronted by families with very diverse needs. Diversity,

culture and context serve as the backdrop for the interpersonal dimension of mental health service delivery. As

such, they inform the conceptualization of services that must meet the needs of a very diverse clientele and must

be taken seriously by the mental health field. Service delivery is often intercultural; the dynamics of cross-

cultural clinical and community work are critically important to understanding and refining our services and

practices. We believe the proposed changes are necessary to address a fundamental problem which negatively

impacts mental health service delivery for multicultural youth and adolescents, and to foster the development of

natural supports that may provide a more efficient use of resources so that diverse children can thrive, especially

those in high-risk communities and settings.

Go to:

Footnotes

This paper was presented at the Conference on Child-Adolescent Mental Health Services Vanderbilt University, September 23, 2009

Go to:

Contributor Information

Margarita Alegria,

Marc Atkins,

Elizabeth Farmer,

Elaine Slaton,

Wayne Stelk,

Go to:

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