The Colorado Trust

Access & Utilization
Many barriers prevent communities of color from opportunities to receive or access mental health services. Other barriers result in underutilization of services once they are accessed due to inappropriate diagnoses and service delivery.⁸⁷ Building on the work of Szczepura⁸⁸ and Barnal & Saez-Santiago,⁸⁹ barriers may be categorized into three groups:

• Systemic factors exist within the design of the mainstream mental health system that creates challenges to accessing services and utilization of services as they result in inappropriate services. The systemic factors can relate to the structure of the system and organizations, such as geographical location, funding and the availability of culturally-traditional mental health services.
• Delivery system factors can also create barriers to utilizing services and include scheduling, staffing, staff cultural competencies, confidentiality concerns and the socio-cultural dynamic between therapists and racial and ethnic clients.⁹⁰
• Cultural disconnects that result from the complexities of different cultures and the gap between those cultures and mainstream providers resulting from differences in personal backgrounds, characteristics and needs; demographic characteristics; cultural factors including language barriers; individual factors; worldview; and individual needs to be addressed in order to provide equitable mental health care.

Access
Systemic factors limiting access to mental health services include the unavailability of private insurance, lack of mental health coverage in health insurance plans and limitations of public insurance programs like Medicaid and the Child Health Plan Plus (CHP+). Beyond a lack of insurance, the unavailability or lack of financing for culturally-specific services⁹¹ limit access to appropriate mental health care. Geographic location of mental health services (e.g. in rural communities) can result in access barriers when linguistically or culturally-appropriate services are not available or readily accessible to communities of color.⁹²

• One systemic access barrier for American Indians is the extreme under-funding of the Indian Health Service’s mental health program. IHS provides roughly two psychiatrists and four psychologists for every 100,000 American Indians, in contrast to the 14 psychiatrists and 28 psychologists for every 100,000 Americans in the general population.⁹³ Though they may access services through local government, the services are unlikely to be culturally-appropriate.⁹⁴ Access to services that integrate mainstream and traditional services or provide a more holistic approach, such as systems of care or integrated substance abuse and treatment services, may enhance outcomes for American Indians.
• Other communities of color experience different barriers as they seek to address their severe emotional needs. Many immigrants living in rural areas may face additional culture, language and transportation barriers to accessing mental health services. The lack of mental health infrastructure, combined with the increasing needs as isolated and diverse populations move into rural areas, limits the services available, particularly to families without health insurance. The lack of bilingual and bicultural providers poses a significant access issue in both rural and urban areas. Even when mental health services are geographically available, mental health services within the school system may not always be available or be able to identify and meet the mental health needs of youth in a timely and culturally-appropriate way, contributing further to access barriers.⁹⁵
• The under-treatment of mental illness among Asian Americans is attributed to such causes, as the lack of recognition of mental health issues among this population, stigma leading to non-treatment and somatization, or the expression of emotional distress in terms of physical symptoms.⁹⁶ Even if an individual accesses physical health services, access to mental health services may continue to be limited due to presenting symptoms that were primarily identified as physical and not psychological. The distinction between mind and body common among individuals in industrialized Western nations is not shared throughout the world. As a result, some racial and ethnic populations may not differentiate bodily from psychic distress and some populations may express emotional distress in somatic terms or bodily symptoms.⁹⁷ For example, for many Chinese patients depression simply does not fit within their cultural context and, as a result, the psychological symptoms of depression are discarded and physical complaints or “somatic symptoms” are shared instead.
• Access to mental health services often may be further prevented by a lack of knowledge of available services. Without a network of family and friends or information available in one’s own language, recent immigrants may have no way of knowing what services are available when mental health needs emerge. Without this knowledge, or help in identifying the mental health issue, accessing mental health services in a timely manner becomes increasingly difficult.⁹⁸

Utilization
Mental health service utilization rates for communities of color are lower than the general population, despite having similar prevalence rates of mental health needs.⁹⁹ One barrier to utilization is the lack of racial and ethnic congruence between staff in the mental health system and the people they serve. Due to cultural differences, providers can communicate in ways that lead to misunderstandings, misdiagnosis, inappropriate treatments and premature termination of treatment.¹⁰⁰ For example, Asian Americans have been found to underutilize mental health services even when they are available¹⁰¹ and African Americans and American Indians have been found to be more likely than the general population to prematurely terminate mental health treatment.¹⁰² Studies have suggested that Latinos will remain in therapy longer if they are treated in a mental health center in their community and by individuals who are aware of their culture.¹⁰³ Increased drop-outs result when they receive culturally inappropriate treatment and perceive that they are misunderstood.¹⁰⁴

The disconnect arises not only from the lack of congruence between the racial and ethnic make-up of providers and the people they serve, but also from a lack of provider education in the cultural and sociopolitical factors that the American Psychological Association (APA) emphasizes must be incorporated into treatment.^105,106 The APA emphasizes this need, instead of focusing exclusively on the individual issues that result from attempts to adjust to the social and political conditions.¹⁰⁷ The APA recognizes and emphasizes these factors such as generational history, the history of migration, citizenship status, English fluency, the support of family and community, and the level of stress resulting from acculturation.¹⁰⁸ They may also hold strong stereotypical views, lack cultural awareness and ability, or generally manage patients from diverse backgrounds and different acculturation levels in an unsuitable manner which can create barriers and generate resentment.¹⁰⁹

The APA general guidelines state that “psychologists are encouraged to recognize that, as cultural beings, they may have attitudes and beliefs that can detrimentally influence their perceptions of, and interactions with, individuals who are ethnically and racially different from themselves, and to “recognize the importance of multicultural sensitivity/ responsiveness, knowledge and understanding about ethnically and racially different individuals.”¹¹⁰ The APA emphasizes five crucial ingredients for the establishment of specialized multicultural clinical training programs: commitment, funding, extensive outreach, cultural diversity (in training curricula and recruitment of minority faculty and students) and social support.¹¹¹

Many communities of color may be dissatisfied with the care they receive due to cultural disconnects between themselves and formal mental health providers.¹¹² After a negative experience with a mainstream mental health provider, rather than returning, they often seek out other more culturally-understanding providers when new health problems, preventive needs or referral needs arise.¹¹³

• For example, American Indians who seek out mental health services within the mainstream mental health system are more likely than not to fail to return for a second visit, suggesting significant disconnects between the services they receive and the services they need.¹¹⁴

Utilization barriers may also emerge related to diagnosis and proper treatment. The interpretation of mental health symptoms varies across cultures and can lead to different ways of understanding and diagnosing symptoms.¹¹⁵ Lack of adequate clinical training and culturally-appropriate provision of services to communities of color can result in the perpetuation of negative cultural stereotypes and the provision of ineffective and potentially harmful treatment.¹¹⁶ Communities of color may often be over-pathologized because their cultural practices and worldviews do not fit into a Eurocentric psychological framework and training that providers receive.¹¹⁷

• In general, patients with Asian backgrounds respond more positively to therapists who take active and assertive roles, which conflicts with the training of many mainstream therapists.¹¹⁸ Therapists who focus on independence and individuality also conflict with the cultural expectations of many Eastern patients, where collective cultures emphasize familial and social interdependence and spiritual worldviews.¹¹⁹
• Parents from certain cultures may be insulted when therapists encourage their children to be verbally, emotionally and even behaviorally expressive. Such behavior may be viewed as being disrespectful and undermining of the parents’ authority.¹²⁰
• Beyond the dynamics of the interaction, the simple use of verbal communication in counseling assumes that there is a universal meaning to the words and meanings that immigrants who speak English as a second language may not know.¹²¹ Talk therapy, though assumed effective, is not always, particularly when the patient does not see a dichotomy between mind and body.
• People from the East who manifest and communicate problems through their body, even when the problems are psychological, need more holistic approaches to healing.¹²²
• Gender issues may also play a role in an individual’s inability to engage in talk therapy as men and particularly Asian American men, have been socialized to hold negative attitudes toward counseling.¹²³

The limited availability of interpreters and linguistically competent providers and culturally-traditional or -specific providers is another significant barrier. Sometimes children are asked to translate for the parents. Even when an interpreter is available, the interpreter may not be from the same culture or acculturation level as the family, risking misinterpretations of what they are trying to express. This emphasizes the importance of discussing the choice of interpreters with families to ensure that the interpreter can meet their cultural and confidentiality needs.¹²⁴

Linguistic and other barriers are compounded by the varying levels of acculturation within different communities of color, where adaptation to the mainstream culture can impact access and utilization of mental health services and mental health outcomes.¹²⁵ Acculturation has many different definitions. One definition is, “the process whereby immigrants change their behavior and attitudes toward those of the host society”¹²⁶ or dominant culture. Acculturation can be measured at an individual or group level, but one’s acculturation level affects their adaptation to society. Acculturation can be measured through variables such as language familiarity, usage and preference; generational status, distance and ethnic self identity and pride; social class; cultural heritage and ethnic interaction and other factors such as reasons for leaving their country of origin, as well as the initial attitudes about the host country or the degree to which a person feels comfortable in one or another culture.^{127,128,129,130,131,132}

Different levels of acculturation can increase access and utilization of mental health services, but also increase some mental health issues. Factors such as an individual’s linguistic ability, bicultural status, comfort with their cultural status and sense of alienation can have an impact on physical and mental health status.

• For example, Spanish-speaking Mexican Americans report significantly fewer problems of social relations yet more anxiety issues than more acculturated Mexican Americans (who speak English and/or are bilingual).¹³³
• First generation Mexican Americans demonstrate fewer psychological difficulties than third generation and culturally blended (bi- or multicultural) groups that rate themselves as having lower physical and mental health status than Anglo-oriented or Mexican-oriented (monocultural) groups.¹³⁴
• Depending on the conditions of an individual’s immigration, whether a refugee from a war torn country or turbulent experience or the circumstances and comfort upon arrival, may result in culture shock, anxiety or depression, or a sense of powerlessness or loss of self esteem.¹³⁵

Acculturation can also influence the effectiveness of mental health interventions.¹³⁶ Mental illness affects the ways people think about themselves and their worlds, relate to others, interrelate with families and social networks. Culture and acculturation level impact the different ways in which individuals perceive and treat mental illness. Therefore, in order to effectively treat mental health problems across cultures, it is necessary to “sort out what is culturally normal and abnormal”¹³⁷ Culturally-appropriate services include providing services that are consistent with the values of communities of color, increase cultural understanding of issues relevant to the client and incorporate acculturation factors and the client’s ethnic identity into the larger framework of the self.¹³⁸