Improving Access to Minorities’ Mental Health Care
- 1. Retired Counselor Educator, Washington D.C. 20007, USA
Many members of minority groups of our population do not find it amenable to consult or visit mental health centers and counseling professionals. There are many reasons why this is so. This article discusses what mental health clinicians can do to improve access to minorities’ mental health care. The suggestions and points raised with support from reviewed literature can ultimately lead to improved visits from this population. Discussions about training, encouraging, empowering, learning from and understanding minorities’ culture were discussed.
Adekson MO (2018) Improving Access to Minorities’ Mental Health Care. JSM Health Educ Prim Health Care 3(2): 1046.
The Constitution of the World Health Organization (WHO) states that the “enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition” (Preamble to the Constitution of World Health Organization, New York, 1946, as quoted in Blondeel et al., . Another World Health promulgated paper posited in 2011 that “although medical ethics require health services to be inclusive of all people, some populations have more difficulties than others in reaching this standard of health” (WHO, 2011 Paper as quoted in Blondeel et al., reiterated that, “these populations can be defined by age, gender, race or ethnicity, geography, wealth, disability, and also by sexual orientation and gender identity”.
Vega and Rumbaut pointed out that “Community Mental Health Centers (were) provided (through) federal legislation in 1963” . Since then, there have been disparities in the provision of mental health care for minorities. There is a need for the discussion on what can be done to prevent the disparity in the provision of mental health care for minorities. This article therefore highlights the major points that will help improve mental health access for minorities.
Kim et al. , reiterated quoting the National Institute of Mental Health that, “recent statistics show that approximately 61.5 million Americans suffer from mental illness in a given year but less than half of these adults receive treatment” (p.939). These authors added that, “previous research documents existing disparities in unmet mental health care need in the US by reporting that racial/ethnic minorities tend to have significantly higher unmet need for mental health care than non-minorities” . Kim et al., concluded that, “racial/ethnic disparities in unmet need for mental health care varied by geographical region in the US” (p.947). These authors pointed out further that, disparities at the regional level contributed to disparities at the national level and they advised that policy makers should be cognizant of this fact in implementing mental health policies.
There is an urgent need to integrate cross-cultural curricular early and throughout training in counseling, psychology and social work. Clinicians’ acquisition of appropriate knowledge, skills and awareness will enhance the advancement of counseling for minority clients. This kind of training will allow future mental health clinicians to understand minorities and their cultures and thereby improve their perception of cross-cultural interactions. This will aid in improving what has been perceived as hindrance of minority clients’ access to quality mental health care. Tremendous efforts have been made in this regard as depicted in discussions [4-7]. Nevertheless, all trainees need to be exposed to cross-cultural curricular in all their courses and post profession workshops if this experience is to become part and parcel of their professional life.
EDUCATION IS KEY
Educating minorities about the meaning of mental health, counseling and about their rights in clinical decision-making will help minority clients appreciate the helping profession. In other words: empower minority clients with appropriate knowledge about mental healthcare and or counseling. Since most minority clients are not conversant with what counseling is and what counselors do within therapy, educating them about the meaning and what entails within therapy will open their eyes to the demands and expectations embedded in this professional relationship. This in turn will prevent misconception about what counseling is. Education is therefore important especially since some minority clients view psychiatric disorders as biologically based.
Health insurance agencies need to be curtailed and educated about how to treat minority consumers. Education will lead to the understanding that misdiagnosing minority clients is not based on fielding their symptoms with their low-income status; stress associated with this fact and also with misidentification of mental health problems with physical health problems. Kolody et al. , pointed out those minorities disproportionally experience health problems because they are from low social economic status and likely suffer psychophysiological distress and depressive mood as a result of this consequence. Some other times too, as Kleiman , reiterated, some ethnic minorities ‘somatize’ psychological problems. It is therefore important for mental health clinicians to adequately verify all information before sending in diagnosis to the health insurance experts. Workers in health insurance companies should be educated about the diagnosis they receive from clinicians. Mental health clinicians should arrange financial and institutional health systems in a way that will prevent their acting as barriers to getting adequate mental health care. Sliding fee scales or bona fide free service should be considered for qualified minority clients where possible. This assistance should not be for those clients who are on Medicaid, Medicare nor having the privilege of getting government subsidies. Provision of “additional resources to encourage or empower patients to interact with the formal health care system and/or health care providers”  is key to preventing inadequate mental health care.
HAVING HELPERS WHO LOOK LIKE THEM
Encourage minorities to enter the mental healthcare fields such as counselors, psychologists and social workers. This move will encourage minority clients to come to therapy where they can have access to clinicians who look like them and/or understand their culture. Vega and Rumbaut  posited that “minority mental health has been understudied because there have been few minority researchers, and (that) people of color often have not been (adequately) represented,” (p.356) within the mental health field.
Studies show that ethnically-matched dyads in therapy (client/clinician) improve treatment duration and outcomes among ethnic minorities. Ability to communicate in the same language and have the same culture-match go a long way to stabilize treatment. Limited number of clinicians in the mental health profession poses a hindrance to attaining ‘ethnicmatching’. There is no gainsaying that communicating content and context rather than just ethnicity improve outcomes and participation and they can only be attained through the right training .
TRAINING MAKES A LOT OF DIFFERENCE
Mental health clinicians need to be trained to understand and treat minorities as human beings first before assessing their problems. They should develop and elicit empathy, which “connotes the comfortable and unconstrained relationship of mutual trust and confidence”  between them and their clients. Mental health clinicians should also be able to build rapport, which according to Hinsle and Campbell  “is the existence of a mutual responsiveness” (as quoted in Vontress , with their clients. Atkinson et al. , reiterated that “the counselor (should) establish a working rapport with the client so that the client’s, not the counselor’s goals are being pursued” in therapy.
Mental health clinicians should be trained to understand both their minority clients’ general and unique cultures. Success in therapy will result from understanding their clients’ cultures . “Educational programs and trainings to improve professional students’ and providers’ cultural competence behavior are the most prevalent type of cultural competence intervention” . These authors concluded that “improved cultural competence leads to reduction in health care disparities as well as decreased bias and discrimination”  supported this point by pointing out that, “culture is inextricably linked to medical (and also mental health) communication in determining the topics deemed suitable for discussion (content) as well as the use of vocabularies and linguistic registers that convey authority (p.10). “Semi-structured interviews such as the DSM-5 Cultural Formulation Interview (CFI) have encouraged clinicians to use patient vocabularies, explore patient interpretations of illness and care, and inquire about concerns in the patient-clinician relationship, targeting communication content and context” .
Mental health clinicians should ask questions about their minority clients’ culture to fully comprehend where they are coming from and what they are going through in their individual and family circles. Atkinson et a. , posited that understanding client’s level of acculturation is one of the factors that needs to be taken into account when a “counselor selects the role (s) and strategy (ies) to adopt when working with a racial/ethnic minority client. These authors asserted, quoting Redfield , that “acculturation is the process that occurs when two cultures come in contact with each other” . Atkinson et al. pointed out that “with respect to an individual member of a racial/ethnic -minority group, acculturation refers to the extent to which he or she has adopted the beliefs, values, customs, and institutions of the dominant culture”. What this is saying is, according to these authors’ explanation, (is that) minority clients’ cultures are the ones that have “undergone the significantly greater change”. It is therefore important for mental health clinicians to understand the culture of the client . Ask the question and try to understand where minority clients are coming from and why they believe in what they believe. Make a referral to more experienced professionals when appropriate and utilize the help of experienced minority professionals who have the necessary expertise where applicable and available. Locate and use appropriate role models for your minority clients. Johnson and Lashley  pointed out that, “students with a strong commitment to Native American culture expressed a greater preference for an ethnically similar counselor and a greater expectation for nurturance, facilitative conditions, and counselor expertise than did respondents with a weak commitment to Native American culture” .
FAMILY AND TRADITION ARE THE CUSHIONS FOR POSITIVE MENTAL HEALTH AMONG MINORITIES
It is therefore important to involve families and talk about traditional values in therapy as positive cushions for positive mental health among minorities. Families are mostly the glue that holds minority clients together. It is therefore important for mental health clinicians to include family members in decisionmaking during and outside therapy. Home visits might in some cases be encouraging and empowering where considerably necessary.
Mental health clinicians should be encouraged to understand themselves. Self-understanding paves the way to understanding others. Atkinson et al. , professed that, “in particular, we believe that counselors need to continuously engage in a process of self-examination, a theme that has been echoed in several noted works in the cross-cultural literature”. King et al. , posited that, “people in our profession, both students and practitioners, (should) know themselves as thoroughly as possible as a prerequisite to effective interpersonal helping” .
Mental health clinicians should be sensitive to how their culture and outlook affect how they behave and relate to their minority clients. This is particularly important and true where clinicians are from the dominant White American culture. Mental health clinicians should be sensitive to and be able to evaluate how their minority clients perceive themselves vis-à-vis the dominant culture. Clinicians should assist their clients by setting up preventive programs that will hopefully help “ward off or at least minimize the problems that will result from racism and discrimination”  and that will hopefully eventually, “help change an unhealthy or unproductive system” . These authors added that “practitioners working with any racial/ ethnic minority client need to be trained in (and to internalize) the requisite knowledge, skills, and attitude to enable them to be sensitive to cultural influences and ever vigilant to the impact of external forces (discrimination and oppression) on the problem” . Atkinson et al., advised further that, counselors “need to be sensitive to the unique experiences of racial/ethnicminority clients” (p.272). Aggarwal et al., posited that, clinicians should understand that patients possess their own cultural interpretation of illness and care and therefore work hand in hand with patients to understand these.
COUNSELORS OWN AND ACCEPT YOUR FEARS AND DISCREPANCIES
Mental health clinicians should be able to identify and work on their biases, fears, prejudices, superstitions, expectations, stereotypes, and discriminatory behaviors that might impede their work with minority clients. This presupposes and entails constant assessments and reassessments throughout their professional life. Know and asks yourself as a mental health professional: How do I view my minority client? Avoid generalizing when relating to minority clients and their families in therapy because to treat everyone the same is discrimination. Respect your clients. Clinicians should have empathy and compassion and be genuinely caring towards their minority clients because people don’t care how much you know until they can see how much you care.
Place your office and environment in a location that will be easily accessible to minority clients. Most minority clients will like to visit mental health centers that are located in a government building, or a medical building or a not-so-conspicuous location. This disallows friends and relatives from knowing that they are there to get help for mental health problems. This is important because of the stigma associated with mental illness. It is therefore important for mental health clinicians to familiarize themselves with the stigma associated with mental illness among minorities and be ready to educate and encourage where necessary.
Clinicians should be careful about their choice of words and also try to understand their minority clients’ verbal and nonverbal language. Where called for, use professional and proficient translators in your daily interactions with minority clients. This is a valid point when it involves newly arrived immigrants who speak limited English.
Clinicians should be an advocate, empower, educate, love, respect and encourage. Atkinson, Morten and Sue  advised that “counselors should also function as facilitators of self-help, outreach workers, consultants, ombudsmen, and facilitators of indigenous support systems” .
ENCOURAGE AND EMPOWER
Encourage your minority clients to discuss stressors, anxiety, emotional points of view related to being a minority within the American culture. Anomie, powerlessness and alienation can be sources and reasons for stressors that can lead to hopelessness for minorities in the United States.
Be fair and discuss appropriateness of diagnosis and medication because most of the time according to research there had been misdiagnosis of minority clients. Vega and Rumbaut  supported this point by pointing out that,”nonwhites were found to have higher rates of ‘insanity’ than whites in 1930 and in every census report since then” (p.364). Encourage mental health researchers to look at all the facts related to mental health among minorities and accurately disseminate it to the public. In other words, researchers should not base their facts on hearsay, scanty information or bias research, but on concrete evidence from research done with enough subjects to justify conclusions reached about different minority clients.
COLLABORATE AND REFER YOUR CLIENTS TO THOSE WHO CAN HELP THEM
Where applicable involve the help of traditional healers, folk healers, pastor’s and other religious leaders among your treatment options if your minority clients believe in them. Taylor and Chatter  posited that “African Americans described themselves as either ‘fairly religious’ or ‘very religious’ in a survey. Other minority clients also hold different religious beliefs that mental health clinicians need to pay close attention. There might be a need to seek consultation with religious leaders, traditional and folk healers where applicable and necessary to the enhancement and progress of minority clients’ mental health. Adekson discovered through her research with healers in two continents that clients prefer and consult healers for their problems because of similarity in culture and also because they grow up among healers [22-27]. Clients’ comfort level with healers is an important variable that counselors should consider when interacting with their culturally different clients. Atkinson et al. , advised that “by facilitating the development of support systems that evolved in the client’s culture to prevent problems, the counselor can help prevent the manifestation of intrapsychic problems in the new culture”. These authors advocated referral to indigenous healers and religious leaders as appropriate venues for facilitating the necessary help for minorities’ clients who have this need.
Aggarwal et al. , pointed out that, “a better examined phenomenon has been the integration of mental health and primary care services through collaborative care to avoid interruptions in clinician referrals. In other words, housing mental health clinicians and primary care physicians in the same building is bound to foster healthy emotional growth and wellness and most possibly reduce outlooks related to the stigma of visiting predominantly mental health clinics.
OTHER LIFE STRESSORS
Be aware of other life stressors like those involved with disrupted marital statuses, unemployment, homelessness, financial problems, disparities and problems within the family, fragmented social networks, stigma, medical mistrust, physical hardships, low social support, anxiety about immigration issues, experiences of discrimination, problems communicating with providers, bias ( both conscious and unconscious), confidentiality issues and other life stressors related to being a minority with low social economic status. Clinicians should encourage their minority clients to express their perceptions of their problems accurately and also listen to them and work with them to sort out their positive and negative perceptions. Encourage minority clients to make decisions for themselves, with your encouragement, in and outside therapy. Taylor and Chatters  pointed out that “African Americans may prefer indirect assistance including general encouragement, companionship, and social and spiritual advice”  in their quest for help.
Hall and Theriot , advocated that mental health clinicians “must know the resources available to the client and how they may be best used”. They (Hall and Theriot) further stated that, “various aspects such as ethnic identification, socio-economic status, migration history, gender, age, religion, and physical capabilities have a profound impact on a (client’s) way of life”. Having the resources that could aid minority clients to further enhance the therapeutic outcome might be a catalyst to their willingness to continue in therapy.
IMPROVING ACCESS FOR SPECIAL POPULATIONS
There is a need for a change in attitude of health care providers to sexual and gender minorities. Blondeel et al. , defined “sexual and gender minorities (SGM) to include individuals with a wide range of sexual orientations, physical characteristics and gender identities and expression”. These authors pointed out further that, “data suggest that people in this group face a significant and poorly understood set of additional health risks and bear a higher burden of some diseases compared to the general population”.
Societal acceptance of SGM as respected individuals by health care providers and all stakeholders who interact with them will go a long way in enhancing their mental health. It is about time for society to change an outlook on the gender norms and cultural traditions vis-à-vis sexual and gender minorities. General education in medical schools, mental health, psychology and social work programs on different mental health preventive and treatment modalities for these populations should become mandatory. According to Russell and Fish  “given the social/ historical context, and despite increasing social acceptance, mental health is a particularly important concern for lesbian, gay, bisexual, and transgender (LGBT) youth”. Clinicians should show respect, fairness and empathy, encourage resilience, empower,advocate, avoid prejudice, and show unconditional love and humanity to SGM youths and adults. This is very important because of stigma associated with clients from this population. Since the suicide rate has been shown through research to be high for this population, clinicians should assess for suicide ideation or attempts. This is because, Fergusson et al., found through their study that, “LGB youth were more likely to report suicidal thoughts or attempts, and experienced more major depression, generalized anxiety disorders, substance abuse/dependence, and comorbid diagnoses, compared to heterosexual youth” .
Most of the points we raised for improving access to minorities’ mental health above also apply to this special population in how clinicians’ approach and treat them. Families should be an important part of discussion and treatment. Russell and Fish  concluded that “laws and policies provide the broad, societal-level contexts that shape minority stress and consequently mental health”. In this case as these authors pointed out, “legislation specifically relevant for LGBT youth mental health”, should be enacted for their wellness and positive mental health to avoid “stigma- related stressors and psychological distress”.
It is important for policy-makers to work on developing a culturally competent mental health delivery system for all age groups. There is particularly a need to increase education on gerontology issues particularly related to the mental health of ethnically minority older clients and patients around the world in medical, counseling, psychology and social work programs. There is an urgent need for specialization in gerontology to allow for clinicians and medical specialists who are versed in the knowledge of older persons and their physical and mental health needs. With the increase in older patients and clients, dementia, depression, substance abuse, suicide, and other mental health problems are bound to increase. Bhattacharyya and Benbow  pointed out that, government policy documents have highlighted gaps in services for black and minority ethnic groups in the United Kingdom. Medicare and Medicaid services in the United States should cater to the needs of minority ethnic clients with mental health issues too. Since most of these populations are of low social economic status, there is a mandatory need that policies be enacted to assist them in accessing mental health services. Bhattacharyya and Benbow  advocated that mental health centers should include “the employment of bilingual health care workers and community psychiatric nurses, ready availability of professional interpreters, staffing composition reflecting local demography, and close collaboration with local voluntary sector organizations” in all their interactions with elderly clients and patients
Involving families and community in the treatment and mental health needs of the elderly minorities are crucial to the enhancement of their mental health and wellness. The discussions on culture, education, interactions with clinicians, collaboration and empowerment are all mandatory to the growth of elder mental health care. Special funding and departments should be designated for minority mental health care in order to increase overall wellness in this population.
Mental health clinicians need to reassess and reaffirm their stance as professionals who can cater for the needs of minority clients. This is very important now that the United States census reveals that there will be more minorities within the United States population in the coming decades. Mental health professionals need to be ready. Anti-stigma programs should be incorporated into the mental health setting. Clement at al. , reiterated that “the stigma associated with mental illness may be an important factor reducing help-seeking. Link and Phelan defined stigma “as a process involving labelling, separation, stereotype awareness, stereotype endorsement, prejudice and discrimination in a context in which social, economic or political power is exercised to the detriment of members of a social group” . Clement et al., added that, “services and practitioners could, for example, support service users to develop additional strategies to cope with, and counter, treatment stigma and to address internalized stigma”. Both clinicians and clients should be educated and empowered that “brain disease” is not different from physical disease and that taking medication to care for “brain disease” should not be looked at as inferior or regarded as a weakness, ‘craziness,’ or character defect. Clement et al. concluded that “combining anti-stigma programmes with those addressing mental literacy,” are key to stigma-reducing strategies. It is therefore important for policy-makers to work on developing a culturally competent mental health delivery system for all ages and diverse groups to aid access to wholeness and enhanced mental health within the population.
The above discussions highlighted and presented viewpoints would therefore be helpful as a preparation for the upsurge of minority clients that will be on their doorsteps. These points will enhance the growth of mental health services and discourage the negative misconceptions that have prevented minority clients from accessing and enjoying mental health services.
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