# Presentation: 312234

## The Immunity Hypothesis: Using Cultural Competence to Eliminate Disparities in Mental Health Services

*December 13, 2003*
- King Davis, PhD, Executive Director
*Hogg Foundation for Mental Health Services, Research, Policy & Education*
*Robert Lee Sutherland Chair in Mental Health & Social Policy*
*School of Social Work*
*The University of Texas at Austin*
- Austin, Texas

## The Immunity Hypothesis

- “Slaves are immune from stress and from the subsequent risk of mental illness because they do not own property.”

- John Galt, M.D.(1840)

## Purpose of the Presentation

- Conceptualize the term disparities
- Place disparities in context
- Link various types of disparities
- Define key terms
- Link disparities and cultural competence
- Identify key causative variables
- Relate to New Freedom Commission
- Get out alive!

## Foci of the Presentation

- Disparities have an extensive history
- Disparities are related to a perverse conceptualization of people of color
- This conceptualization pervaded clinical practice, research, education & policy
- Disparities are imbedded in differences in income, access to information, and cultural traditions & social structures

## Four Critical Realities

- Universities, professional schools, and professional associations are responsible for the level of knowledge, skills, theory, and clinical practice that is applied to people of color.
- Cultural competency is not an acceptable approach in the majority of university based education programs.
- Most people of color seek help first from religious organizations.
- Collaboration/cooperation between religious organizations and behavioral health is minimal.

## Conceptualizing Disparities

- Prevalence		Rehabilitation
- Incidence		Participation
- Services		Outcomes
- Treatment		Acceptable Norms
- Prevention		Personal Choice
- Recovery		Racial causation

- King Davis, 2003

## Service Disparities

- Racial, ethnic, and cultural differences in twenty characteristics designed to define and describe the nature of behavioral health service provision
- Source: K. Davis (2003)

## Service Disparities 1760-2000

- >**Frequency of Inaccurate Diagnosis**
**>Findings of Severe Mental Disorder**
**>Inpatient Hospitalization/LOS**
**>Involuntary Commitments**
**>Recividism/Relapse**
**>Involvement in Criminal Justice System**
**>Mortality Rates (Primary Health Problems & Suicide)**
**<Recovery**
**>Uninsured/Underinsured**
**<Access to Outpatient/Early Access**
**<Access to Providers of Color**
**<Utilization of Cultural Competency in Service Design**
**<Participation in Behavioral Health Volunteer Organizations**
**<Access to Information about Behavioral Disorder/Services**
**<Family Support**

## Service Disparities

- >Delays in help seeking
- <Housing alternatives
- <Access to trained interpreters
- <Inclusion in research/clinical trials
- >Executions while mentally disabled
- <Integrated behavioral health services

## DISPARITIES IN MENTAL HEALTH CARE FOR RACIAL AND ETHNIC MINORITIES

- Minorities have less access to, and availability of, mental health services
- Minorities are less likely to receive needed mental health services
- Minorities in treatment often receive a poorer quality of mental health care
- Minorities are underrepresented in mental health research
*      **Mental Health: Culture, Race, and Ethnicity, a Supplement to the Surgeon General’s Report  on Mental Health*

## Expanded View of Disparities

- Dental
- Health

- Health

- Economic

- Educational

- Substance

- Mental
- Health

- Employment

- Political/
- Legal

- King Davis, 2003

## An Expanded View of Disparities

-   Cardiovascular
- Disease

- Depression

- Sickle
- Cell

- Schizophrenia

- Periodontal
- Disease

- Diabetes

-    HIV

- Alcohol
-  Abuse

- Cancer

- Obesity

- Bipolar

- Personality
- Disorder

- Dementia

- Homicides

- Domestic
- Violence

- Unemployment

- Environmental
- Pollution

- Low Birth
- Weight
- Babies

- Low
- Income

- Asset
- Accumulation

- Voting

- Political
- Office

- Sentencing

- Criminal
- Justice

- Cocaine
- Use/Sale

- Housing &
- Homelessness

- Nutrition

- Literacy

- Maternal/
- Infant
- Deaths

- Mental
- Retardation

- Uninsured

- Graduation
- Rates

- Crime
- Victims

- Capital
- Punishment

- King Davis, 2003

## Causes of Disparities

- Societal policies: race, gender, income
- Focus/content of professional education
- Focus /content of research
- Service design and implementation
- Cultural traditions: beliefs/help seeking
- Dissemination of information
- Bundling health care to employment

## Removal of Disparities

- Recent efforts at the federal (Clinton 1994) presidential level are designed to eliminate disparities in health and mental health by 2010;
- President Bush (2003) has included this goal in the recent report on mental health
- Bush identifies cultural competence as the vehicle for eliminating disparities in mental health

## A transformed system: Recovery

- To achieve the promise of community living for everyone, new service delivery patterns and incentives must ensure that every American has easy and continuous access to the most current treatments and best support services
- Source: New Freedom Commission

## Six Critical Goals

- Americans understand that mental health is essential to overall health
- Mental health is consumer and family driven
- Disparities in mental health are eliminated
- Early intervention is common
- Excellent care is delivered and research is accelerated
- Technology is used to access mental health care and information
- Source: New Freedom Commission

## Disparities in Mental Health Services are Eliminated

-  In a transformed mental health system, all Americans will share equally in the best available services and outcomes, regardless of race, gender, ethnicity, or geographic location.
- Source: New Freedom Commission

## Recommendations:

- Improve access to quality care that is culturally competent
- Improve access to quality care in rural and geographically remote areas
- Source: New Freedom Commission

## Primary Strategy:

- How to develop & implement?
- What are the key strategies?
- What are the critical challenges?

- State Mental         Health Plan

## The Challenge of Reform:

**Help seeking**

**Voluntary Participation**

**Disproportionate Poverty**

**State Policy Reform**

**Service Redesign: EBP**

**Human Resources**

**General Fund Pressure**

**Health Insurance**

**Federal Government**

**Private**
**Sector**

**System **
**Reform**

**State Government**

## The Immunity Hypothesis

- “Slaves are immune from stress and from the subsequent risk of mental illness because they do not own property.”

- John Galt, M.D.(1840)

## Contextual Hypotheses

- Immunity Hypothesis 1763-1865
- Exaggerated Risk Hypothesis -1865-1980
- No-difference Hypothesis 1981-1990s
-          _____________________
- Immunity Hypothesis Recycled 2001
- Exaggerated Risk Hypothesis Recycled 2001
- No-difference Hypothesis Recycled 2001

## Historical Hypotheses

## Historical Hypotheses - Continued

## Multiple Costs

- Excess Preventable Deaths
- Untreated Illness & Lower Lifetime Achievement
- Excess Hospital Admissions & Readmissions
- Misdiagnosis & Inappropriate Care (LLOS)
- Community Suspicion and Mistrust
- Staff Division and Conflict
- Absence of Scientific Knowledge & Theory
- Ethical Conflict: Professional & Personal
- Increased Taxes & Agency Budgets: Waste

## Differences by Culture

- Access to Services/Treatment
- Increased Risk Based on Low Income
- Help Seeking/Family Participation
- Source of Information/Accuracy
- Involuntary Admissions/Readmissions
- Involvement by Police
- Medication Compliance
- Severity of Diagnosis/Homelessness

## Admissions per 100,000 by Race, Ethnicity & Type of Facility

## Involuntary Admissions by Race & State

## Need for Behavioral Health Care

- _African Americans:_
- Overall rates of mental illness similar to non-Hispanic whites
- Differences in prevalence of specific illnesses
- Suicide rates lower but on the rise
- Environmental, economic and social factors
- Exposure to violence, homelessness, incarceration, social welfare involvement
- Less access to behavioral health services

**Notes:**
Less likely to suffer from Major Depression, more likely to suffer from phobias and culturally bound syndromes
Less likely to commit suicide than whites, although suicide of young black men = young white men and overall suicide rates have increased sharply in past 20 years.
While representing only 12% of the U.S. population, Blacks make up about 40% of the homeless population. 
Nearly half of all prisoners in State & Federal jurisdictions and almost 40% of juveniles in custody are Af. Am. 
African American children and youth constitute about 45% of children in public foster care and more than half of all children waiting to be adopted.
African Americans of all ages are more likely to be victims of serious violent crime than are non-Hispanic whites. One study reported that over 25% of African American youth exposed to violence met diagnostic criteria for post-traumatic stress disorder (PTSD). 
Overall, only one-third of Americans with a mental illness or a mental health problem get care. Yet, the percentage of African Americans receiving needed care is only half that of non-Hispanic whites. One study reported that nearly 60% of older African American adults were not receiving needed services.
More likely to use ER or to seek treatment from primary care provider than from a mental health specialist. Use alternative therapies more than do whites.
Af. Am. of all ages are under represented in outpatient treatment but overrepresented in inpatient treatment. 
While few clinical trials have evaluated the response of African Americans to evidence-based treatment, the limited data available suggest that, for the most part, African Americans respond favorably to treatment. However, there is cause for concern about the appropriateness of  diagnostic and treatment procedures. For example, when compared to whites who exhibit the same symptoms, African Americans tend to be diagnosed more frequently with schizophrenia and less frequently with affective disorders. One study found that 27% of blacks compared to 44% of whites received antidepressant medication. Moreover, the newer SSRI medications that have fewer side effects are prescribed less often to African Americans than to whites. Finally, even though data suggest that blacks may metabolize psychiatric medications more slowly than whites, blacks often receive higher dosages than do whites, leading to more severe side effects. As a result, they may stop taking medications at a greater rate than whites.

## American Indians and Alaska Natives
Limited data on prevalence of MI
One small study with 20 year follow-up found 70% lifetime prevalence of MI
Increase rise of depression among older adults
Suicide rate 1.5xs national average with young males accounting for 2/3 of suicides 
2nd decade of life has highest mortality rate
Alcohol dependence, alcohol related deaths
Little information on service utilization patterns

- Limited data on prevalence of MI
- One small study with 20 year follow-up found 70% lifetime prevalence of MI
- Increase rise of depression among older adults
- Suicide rate 1.5xs national average with young males accounting for 2/3 of suicides
- 2nd decade of life has highest mortality rate
- Alcohol dependence, alcohol related deaths
- Little information on service utilization patterns

- Need for Behavioral Health Care

## Latinos/Hispanic Americans:
Overall rates of MI similar to non-Hispanic whites
Higher rates of some disorders
Anxiety-related and delinquency behaviors, depression and drug use, more common among Latino youth
Higher rates of depression among elderly Latinos 
Culture-bound syndromes:
Susto (fright), nervios (nerves), mal de ojo (evil eye), and ataque de nervios 
Access to behavioral health services is limited

- _Latinos/Hispanic Americans:_
- Overall rates of MI similar to non-Hispanic whites
- Higher rates of some disorders
- Anxiety-related and delinquency behaviors, depression and drug use, more common among Latino youth
- Higher rates of depression among elderly Latinos
- Culture-bound syndromes:
- Susto (fright), nervios (nerves), mal de ojo (evil eye), and ataque de nervios
- Access to behavioral health services is limited

- Need for Behavioral Health Care

**Notes:**
Depression among elderly Latinos often related to health problems
Symptoms of an ataque may include screaming uncontrollably, crying, trembling, verbal or physical aggression, dissociative experiences, seizure-like or fainting episodes, and suicidal gestures.
Latino men have lifetime Incarceration rates are 4xs higher than non-Hispanic whites
Prevalence of t substance use disorders (particularly Heroin in the Northeastern states)
High incidence of PTSD among Central American Refugees. 
40% have limited or no language proficiency in English
Highest rate of uninsured 
Use of curandaros, espritismos and herbalist
Problems with mis-diagnosis 

## Asian Americans/Pacific Islanders
Limited data on prevalence of MI
Existing data suggests overall rates similar to whites
Higher rates of depression, PTSD
Somatic complaints of depression
Culture-bound syndromes 
Lower suicide rates - except elderly women who have the highest suicide rates in U.S.
Refugees with PTSD
Language barrier limits access to services 

- _Asian Americans/Pacific Islanders_
- Limited data on prevalence of MI
- Existing data suggests overall rates similar to whites
- Higher rates of depression, PTSD
- Somatic complaints of depression
- Culture-bound syndromes
- Lower suicide rates - except elderly women who have the highest suicide rates in U.S.
- Refugees with PTSD
- Language barrier limits access to services

- Need for Behavioral Health Care

**Notes:**
43 different subgroups, 100 languages/dialects
35% speak limited English (especially those over age 13)
Hmong (from Laos), Cambodian, Laotian, Vietnamese, Korean, and Chinese-American households are linguistically isolated.
Culture-bound syndromes such as neurasthenia and hwa-byung Neurasthenia is characterized by fatigue, weakness, poor concentration, memory loss, irritability, aches and pains, and sleep disturbances. Hwa-byung, or "suppressed anger syndrome," is characterized by symptoms such as constriction in the chest, palpitations, flushing, headache, dysphoria, anxiety, and poor concentration.
70% of Southeast Asian refugees receiving mental health care met diagnostic criteria for PTSD. In a study of Cambodian adolescents who survived Pol Pot's concentration camps, nearly half experienced PTSD and 41% suffered from depression 10 years after leaving Cambodia.
Shame and stigma are believed to figure prominently in the lower utilization rates 
AA/PI clients matched with therapists of the same ethnicity are less likely to drop out of treatment than those without an ethnic match. 
Preliminary studies suggest that AA/PIs respond clinically to psychotropic medicines in a manner similar to white Americans but at lower average dosages
More research needed

## Basic Assumption

- Culture is an important variable in determining how people (consumers, staff & providers) see and interpret (know) the world around them and the basis of how they make decisions.

## All Health Care is Cultural

- Conceptualization
- Diagnosis
- Treatment
- Training
- Research
- Policy
- Help Seeking
- Compliance
- Participation
- Health Beliefs
- Expectations
- Employment

## Defining Cultural Competence 

-                Market-Based Definition
- Cultural competence is the integration and transformation of knowledge, information, and data about individuals and groups of people into specific clinical standards, skills, service approaches, techniques, and marketing programs that match the individual’s culture and increase the quality and appropriateness of health care and outcomes (Davis, 1997).

## Defining Cultural Competence 

- Cultural competence is the conclusion reached and shared by members of a nation, community, group, organization, business, or a board that constitutes how the individual wants to be treated with respect by others based on their culture (T.Davis, 2002)

## Status of Cultural Knowledge:

- The Clinical Application of Cultural Competency is Relative

- Non English
- Speaking

- Native
- Americans

- Lowest
- Income

- Asian/
- Pacific
- Islanders &
- Indian/Pakistani

- African
- Americans

- Mexican
- Immigrants

- Mexican
- Americans

- Middle
- Income

- Anglo
- Americans

- Men

- Lowest

- Highest

## Elements of Cultural Competence

- Attitudes of respect 		Agency Evaluation
- Beliefs 				Agency Plan
- Knowledge and Skills		Inclusion in Vision
- Language and Communication
- Community Analysis		Inclusion in Services
- Valuing Diversity		Outcomes
- Cultural Self-Assessment	Staffing

## Potential Benefits of Cultural Competence

## Applying Cultural Competence

## Applying Cultural Competence

- Governing
-  Board

- Executive
- Director

- Senior Staff

- Line Staff

- Policies

- Cultural Competence
- Plan

- Vision

- Mission
- Budget
- Goals

- Work
- Plans
- Supervision

- Work Plans
- Implementation

- Strategic Plan
- Budget
- Initiatives

- Consumers

- Feedback
- Input

## Individual

**Individual**

**Degree of**
**Impairment**

**Family**
**Burden**

**Community**
**Stigma**

**Church**
**Organizations**

**Practitioner:**
**Evidence Base**

**Theory and **
**Model: Recovery**

**Consumer **
**Self help**

**PHASE 3**

**PHASE 2**

**PHASE 1**

**DECISIONS TO UTILIZE SOME FORM OF HELP COMMUNITIES OF COLOR**

**Professional: Evidence Based**

**Delayed Help Seeking**

**Self ****Help**

**Religious**
**Based**
**Help**

**Figure 1.****Conceptual Framework**

**C. Individual & Community Factors**

**D. Formal Helping     System**

**B. Number of Psychiatric Episodes**

**Faith**

**Absorption**

**Information**

**A. Organizing Concepts**

**Boundary Expansion**

**Collective Caring**

**Family Choices/Actions**

**King Davis, Hogg Foundation 2003**

## Differential Risk Analysis

- Mental Illness

- Poverty
- Retardation
- Substance Use
- Unemployment
- Institutionalization
- Suicide
- Uninsured

- High
- Risk

- Medium
- Risk

- Low
- Risk

- Severe Mental
- Illness

## Social Marketing

- Consideration and integration of social variables in the design of plans and policies in health care services

-   Study Culture:	   		       Help Seeking
-   Definitions of Health/Illness           Information Use
-   Learning Style             		        Leadership
-   Family Systems          	  	        Media Outlets
-   Languages Spoken                           Schools
-   Religious Ideas           		        Neighborhoods

## Why is Cultural Competence Important?

- Potential Cost Savings: people & dollars
-    a. Excess use of inpatient    d. >Diagnostic error
-    b. High rates of recidivism   e. >Insurance rates
-    c. Under-use of outpatient   f. LOS
- Ethical Base of Professions
- Quality of Care Demands it
- Potential Improvement in Diagnosis
- Potential Improvement in Treatment
- Potential for Prevention
- Potential for Increasing Participation in Policy
- Emphasis on Recovery
- Congruent with Evidence Based Approach
- Congruent with Disease Management

## Useful Techniques:

- Connect Cultural Competence to Public Image
- Link Cultural Competence to Public Trust
- Tie Cultural Competence to Profits
- Include Cultural Competence into the Training Curriculum
- Show how Cultural Competence is Useful to Save Money

## Useful Techniques:

- Decrease the Assumption that Cultural Competence is Affirmative Action
- Decrease the Assumption that Cultural Competence is About Black People
- Provide Training and Education in Cultural Competence for Key Managers in the Organization and Board Members
- Develop Standards and Guidelines

## Useful Techniques:

- Non-Blaming Approach
- Focus on Cost Savings/Marketing Framework
- Focus on Service Improvements/Quality/Data
- Acknowledge Existing Competencies
- Understand Resistance/Nature/Origins
- Recognize Weaknesses in Cultural Competence
- Establish a Realistic Schedule for Change
- Develop a Plan of Action with Education, Licensure, and Accreditation
- Bind Cultural Competence to Vision/Goals

## Who Uses Cultural Competence?

- Coca Cola/Pepsi Cola    Defense Department
- Budweiser 		    NCQA
- General Motors		    JCAHO
- IBM			    Managed Health Care
- Time Warner		    California DMH
- HMOs		 	    Texas DMHRM
- Disney Europe		    Virginia DMHMR
- Makers of Viagra

## Coca Cola in the Bush

## DISNEY OF EUROPE

## DISNEY’S CULTURAL ISSUES

- Marketing to Europeans
- Pricing: Too high in Europe
- Alcohol: Cannot ban drinks
- Language: Uses six different languages
- Differences in Attitudes
- Films: Must adhere to Euro standards
- History: Must reflect Europe
- Famous Figures: Limit American stars

## Disney’s Outcomes

- Tenth anniversary this Year
- 2000 New hotel rooms under construction
- Visitors will exceed 17 million this year
- Profits are up
- Costs are down
- Food does not meet European expectations

## Resistance to Cultural Competence

- New & Unfamiliar Concept
- Incongruence with Prior Education
- Non-traditional Source
- Degree of Change Required - Education
- Lack of Evidence & Tools
- Not Linked to Licensure/Accreditation
- Conceptualization in Black & White Terms
- Potential Cost of Implementation

## New Developments

- National Alliance of all Four Groups has been Formed: Non-Profit Organization, Advocacy, Policy, Training, Research, Workforce Development, Interpretation Models
- Ethnic/racial behavioral health care non-profit advocacy associations: African, Asian, First Nation, and Hispanic

## Development of Standards

## Broad Change Strategies

- Address the pipeline causes/issues
- Support alternative education models
- Focus on continuing education
- Provide training via technology
- Bundle licensure and cultural competence
- Bundle CC with accreditation
- Bundle federal research support to CC
- Provide federal incentives for retraining
- Support development of model curricula CC

## Personal Development Strategies

- Plan your careers and geographic moves well
- Build and use strong cross ethnic networks
- Develop new concepts and theory
- Conduct research and test hypotheses
- Publish & present findings in key journals/books
- Teach in universities/key academic positions
- Hold influential positions in profession
- Advocate & participate in politics
- Provide financial support
- Mentor your replacement (s)
- Maintain your bilingual and tri-lingual skills

## General Conclusions

- Too much new information (format) to access/digest or use
- Transformation cannot occur fully without addressing the complex issue of disparities: knowledge, evidence, research, participation, help seeking
- Transformation comes at a time of significant reductions in state budgets for human services;
- Evidence based approaches must be expanded to include the 4 populations of color;
- Cultural competence offers promise but requires national field testing, cost estimation, educational trials, linkages to licensure, accreditation, and further development;
- Cultural competence must demonstrate outcome and cost efficacy;
- Poverty and related socio-economic issues will affect the application of evidence based approaches;
- New epidemiological studies are needed on the four populations of color to increase knowledge of help seeking and utilization.