Cultural Diversity Series:

Examples From The Field: Programmatic Efforts to Improve

Cultural Competence in Mental Health Services

Executive Summary

Examples From the Field is a collection of descriptions of mental health programs working to improve service delivery to a variety of underserved populations. Examples From the Field grew out of a desire to scan the public mental health environment to see how cultural competence is being understood and implemented and to understand what efforts are being made in various states to improve mental health services to underserved groups. The report represents the results of a survey of state mental health authorities (SMHA's) conducted in late spring 1999. By sharing these program listings, NTAC hopes to:

• provide examples of the range of efforts being made in mental health settings to improve services to diverse consumers;

• enhance the dialogue about culturally competent mental health services through the provi-sion of direct examples of these efforts;

• inspire others with ideas for implementing culturally competent program changes; and

• facilitate networking among providers cultivating culturally competent and linguistically appropriate services, and among state-level planners and program designers implement-ing similar changes in systems of care.

Survey History and Results

In April 1999, NASMHPD and NTAC surveyed state mental health agencies requesting that they identify and provide contact information for public and private mental health programs seeking to provide culturally competent services in their respective states. This survey was intended to scan the environment to determine what efforts are being made in various states and what range of program planning and design is being implemented to improve services to underserved groups. We left it to SMHA staff to guide us to the programs of which they were aware that were intended to address cultural competence in mental health service delivery in their states. SMHA staff in 28 states completed the survey and identified 185 programs. Thus this report reflects a survey response, not an overview of existing programming nationwide. In addition, no specific criteria were outlined to define cultural competency in mental health service delivery.

NTAC staff contacted all of the programs by letter and follow-up telephone calls to obtain detailed program information. Several of the original contacts provided by the states proved to be advocacy organizations that served the needs of one of the identified groups but did not necessarily provide mental health services. We were unable to reach several others, and several programs did not respond to our request for a detailed description. Approximately one-third of the programs identified in the original survey response proved to be both: 1) mental health programs serving diverse consumers, and 2) willing and able to submit a brief program description for publication.

Fifty-seven programs, from 21 states, responded to NTAC's request to provide a 1-3 page program description. Four other program descriptions are included that are abbreviated versions of programs described in other publications in the Cultural Diversity Series. NTAC requested that program descriptions address the following topics:

• population(s) served,

• overview of program history and scope of services and supports,

• culturally competent initiatives or strategies,

• collaborative efforts,

• funding,

• evaluation efforts and results, and

• a contact for further information.

Examples From the Field consists primarily of these program descriptions. No telephone or on-site interviews were conducted. These program descriptions are brief and were written by the programs themselves. NTAC staff edited the profiles only for length, format and consistency of grammar. Not all programs submitted information in each of the areas listed above, so not all of these headings are used in every description. For longer program descriptions gleaned from on-site interviews with programs meeting specific cultural competence criteria, see the 1991 report Towards a Culturally Competent System of Care, Vol. II: Programs Which Utilize Culturally Competent Principles (Isaacs & Benjamin).

Program descriptions are grouped according to the target population served by each program. In this way, program designers, planners and administrators can browse to see how others understand and attempt to meet the needs of members of specific population groups. Some programs were designed to develop broad cultural competency skills, or to address the needs of multiple specific target populations. These programs are described in a separate section titled "Programs Serving Multiple Population Groups"; they are also cross-referenced in the chapters addressing their specific target populations, where relevant. The chapters in this report address:

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• Programs Serving African Americans

• Programs Serving American Indians and Alaska Natives

• Programs Serving Asian and Pacific Islander Americans

• Programs Serving People who are Deaf and Hard of Hearing

• Programs Serving Hispanic/Latino(a) Americans

Observations and Uses

This collection of programs reflects a great range of efforts--from simple improvements in access or translation programs to hiring of cultural competency specialists, engaging in agency self-assessment and working to transform policies and services across the board to reflect the diversity of the community being served. Some agencies have designed programs to reach out to and address the needs of specific population groups; others have brought together members of disparate groups to heal interracial misunderstandings as a way of improving consumers' abilities to function in a multiracial community. Readers familiar with the six-stage developmental model of organizational cultural competency presented in Towards a Culturally Competent System of Care, Vol. I (Cross, Bazron, Dennis & Isaacs, 1989) will recognize programs indicative of several different stages in the development toward "cultural proficiency."

Standards of care for the provision of mental health services to underserved groups are available and are crucial for helping administrators and planners understand the importance of implementing change at every level to truly enhance service effectiveness (e.g., Cultural Competence Standards in Managed Mental Health Care for Four Underserved/Underrepresented Racial/Ethnic Groups, SAMHSA/CMHS, 2000). Although not all programs here appear to be working from a strategic cultural competency plan, each represents an effort toward the provision of more unbiased, effective and accessible care for an increasingly diverse population. The range of options reflected here may help other program planners to set incremental goals, determine achievable levels of investment under current circumstances, or better understand the need for administrative-level leadership to foster thorough policy and practice changes.

Another important potential use for this material is to facilitate resource sharing. Several programs, for example, have put considerable effort into designing staff trainings, involving multiple stakeholders in cultural competence planning, or translating materials for consumers into numerous languages. Many of these programs can be contacted directly for technical assistance in designing similar programs elsewhere; programs that have already produced psychoeducational information or surveys in multiple languages may be willing to share translated materials with other programs serving diverse consumers.

From reviewing the evaluation sections of these program descriptions, it appears that the majority of evaluation strategies assess primarily client satisfaction. This is a particularly crucial form of feedback in assessing a program's ability to serve the needs of diverse consumers. Satisfaction data may be more useful, however, when supplemented by measures of improved functioning in the community, behavior change or symptom reduction. Where more expansive quantitative evaluation is done, the data can be used, for example, to support funding for improved outreach and flexibility of services--both crucial components of culturally competent services. Few programs reported using measures to assess indicators of system-wide improvement in cultural competence of services. To learn more about evaluation tools and systems assessment measures related to cultural competency, see A Practical Guide for the Assessment of Cultural Competence in Children's Mental Health Organizations (Roizner, 1996), or Cultural Competence Performance Measures for Managed Behavioral Healthcare Programs (New York State Office of Mental Health, Research Foundation of New York State, 1998).

Finally, the NASMHPD President's Task Force on Cultural Competency has identified a priority to facilitate networking among those at the state level with the responsibility for improving cultural competence in mental health services. Accordingly, NTAC and NASMHPD have surveyed the state mental health commissioners to compile a list of state-level cultural competency coordinators. Forty-three states and the District of Columbia reported that individuals have been assigned to such positions and provided their names and contact information, which we have included in an appendix to this report. It is our hope that this information will facilitate networking, decrease isolation and the tendency to "reinvent the wheel," facilitate knowledge and resource sharing, and increase options for peer-to-peer technical assistance from states with longstanding cultural competency initiatives to advise those with newly forming ones. More detailed information on the cultural competence activities of individual states can be found in the 1997 report The State of the States (Isaacs Schockley).