Cultural competence is an often heard political buzzword these days, but few people understand what the term really means, especially as it applies to psychiatric services. However, with cultural and ethnic minority groups rapidly on their way to becoming a plurality of the U.S. population, the psychiatric profession is paying much more attention to the issue.

Several presentations at APA’s 2000 annual meeting in Chicago in May helped members understand what cultural competence is, how to implement it in private practice and inpatient settings, and why there is a critical need for culturally competent mental health services.

Andres J. Pumariega, M.D., professor and chair of the department of psychiatry and behavioral sciences at East Tennessee State University, chaired the annual meeting symposium, "Psychiatry and Culturally Diverse Populations." Pumariega, who co-chaired the Cultural Competence Standards for Mental Health Services Hispanic Panel, for the federal Substance Abuse and Mental Health Services Administration, Center for Mental Health Services (SAMHSA/CMHS), explained that the importance of cultural competence is underscored simply by looking at numbers.

"By U.S. Census estimates," Pumariega told the small group who attended the session, "before 2050, we will have no majority population in the United States; we will have cultural and ethnic plurality." Indeed, plurality already exists in Alaska and Hawaii. The demographic shift is expected to reach plurality status in California by the end of next year.

Many major population centers in the U.S. are already at plurality—the Los Angeles basin, the San Francisco Bay area, metropolitan Chicago, and the New York City area, with Detroit, Miami, and Washington, D.C., expected to join that group in the next five to 10 years.

The challenge is made even more difficult by diversity within ethnic and racial groups. For example, the term "Hispanic" is commonly used to refer to individuals who speak a common language, Spanish. However, often no distinction is made between Spanish-speaking Mexican Americans, Cuban Americans, Puerto Ricans, or those of South American decent, all of whom have significantly different cultural backgrounds. Similarly, people who are designated "Asian American" may actually represent more than 40 different ethnic groups speaking as many as 30 different languages.

Culture, Ethnicity in Psychiatry

"Mental health services," said Pumariega, "and psychiatry in particular, have had difficulty in responding to these changes in needs and changes in presentation within these populations."

Although studies estimate the prevalence of psychiatric disorders in ethnic populations to be roughly comparable to those in predominantly Caucasian populations, usage of mental health services differs significantly.

In general, many studies have shown, there is a significant underutilization of community mental health services among culturally diverse populations and a significant overrepresentation in inpatient services, especially of African Americans, followed increasingly by Hispanic Americans and Asian Americans.

Research has documented that members of ethnic and racial minority groups are hospitalized for severe psychiatric illness at a rate three times higher than is the general population. Studies have shown that this is often the result of misdiagnosis or overdiagnosis. African-American males, for example, are three to five times more likely to be diagnosed with schizophrenia than the general population, yet epidemiological studies indicate the prevalence should be roughly the same. Several researchers have found that diagnostic errors were made by clinicians who lacked familiarity with cultural patterns.

The numbers suggest, said Harriet G. McCombs, Ph.D., coordinator for Ethnic Minority Mental Health Services for SAMHSA/CMHS, that mental health services are not being utilized effectively or appropriately by ethnic minorities.

"Access to community mental health services," said McCombs, "has many barriers based in culture and ethnicity. And we know that mental health diagnosis is skewed by these factors."

The inability to speak English in order to communicate effectively with psychiatrists and mental health professionals provides a significant barrier. Social stigma regarding mental illness and psychiatric care is more acutely felt by culturally diverse patients. Often, family members are more tolerant of atypical behaviors and will "hide" a relative with a psychiatric disorder to avoid the shame felt within their cultural community. Fear of psychiatric treatment is also strong in communities dominated by ethnic and racial minorities, according to cultural-competence experts. These patients may defer seeking treatment because of fear of "being locked up" for the rest of their lives.

When culturally diverse patients do finally access mental health services, it is often only as a last resort, said Pumariega. Family support is usually eroded to the point that relatives can no longer cope with the patient’s escalating psychiatric disorder.

However, psychiatrists may need to enlist family members in the care of the patient. Often, especially in Asian and Latin cultures, family support and decision-making authority of family elders overrides the patient’s right to confidentiality. This can be a significant barrier to effective psychiatric treatment.

In addition, Pumariega noted, many ethnic groups are more likely to respond to and stay in treatment if it includes a more holistic approach. Many cultures strongly believe in alternative methods, native healers, and folk beliefs.

Many states are working on developing and implementing guidelines and standards for cultural competence in mental health services, with California being the first to require mental health plans to meet certain requirements.

SAMHSA/CMHS has been working on guidelines, standards, and performance measures in cultural competence for several years. Federal mandates for mental health programs to provide culturally competent services are on the horizon.

Yet some are disappointed that more progress has not been made in the field of psychiatry.

"It’s like preaching to the choir," Francis G. Lu, M.D., told Psychiatric News. Lu, who directs the Cultural Competence and Diversity Program at San Francisco General Hospital, and was the first psychiatrist to open a culturally focused psychiatric unit in the U.S., was involved in 11 different sessions related to cultural competence during the recent annual meeting.

"The attendance," said Lu, "is always low. The people who come already know the importance of cultural competence and believe in its implementation."

Pumariega agreed. "Trying to reach a wider audience is difficult," Pumariega told Psychiatric News. "It is a matter of education and understanding. Once people understand, then the only question is, How do we accomplish it?"

"Fundamentally," added McCombs, "if cultural competence is going to be the hallmark of the mental health system, there are obvious next steps to take." Not only does the system have to change and the focus of services have to change, explained McCombs, but so do the providers.

"What is the role of APA, then?" asked McCombs, "Two things: first, to help ensure that training is looked at to ensure that mental health system staff, including physicians, will be able to cope with the changing demographics of the country and the needs brought on by special populations, and second, to make sure that professionals who are already practicing within the system have the opportunity to train on the issues through continuing education at conferences like this one."

The 11 sessions at the annual meeting were designed to do just that.