Engagement of ethnic minorities in mental health care
Authors: Margarita Alegria, Irene Falgas‐Bague, Hiu‐fai Fong
Journal: World Psychiatry (2020)

Disparities in mental health care for ethnic minorities represent a serious public health concern, but one that could be at least partially remediated. Here we briefly describe lessons learned about how to engage these clients in the clinical encounter, particularly when social identities are not shared between client and clinician, which can lead to unease or distrust. Lessons are intended to augment initiation in care, prevent premature termination of treatment, and offer patient-centered practices. We acknowledge that these recommendations could potentially apply to all clients, but propose that they may be especially beneficial for engaging ethnic minority groups, for whom social and economic disadvantage may amplify differences in social identity between client and clinician. Multiple studies find that ethnic minorities are less likely to initiate, continue or complete mental health and substance use treatments, or adhere to recommended regimens1, 2. Clients’ disengagement from treatment may be partly due to the absence of clinician training to help bridge social identities when these are discordant in terms of perceived social position. Social position, in this context, is defined as ethnic, economic or political hierarchy that clients and clinicians each systematically experience based on their objective characteristics (e.g., age, gender, education, income and occupation) and perceptions of how others value, accept and/or rank them. Perceived social position differentials between client and clinician could augment prejudice and bias and decrease emotion recognition when the clinician is not able to appreciate the perspective of the client3. Therefore, our first lesson is to utilize strategies to overcome positional hierarchies associated with unjustified group attributions, pre-made assumptions, and imbalanced relational power characterizing client-clinician interaction4. Shared decision making in the clinical encounter rebalances power and encourages a collaborative dialogue between clinician and client5, one where the client brings expertise of his/her illness and the clinician brings expertise of diagnosis and treatment. Shared decision making includes negotiations toward a shared agenda for the session (“What would be helpful for us to talk about?”), client involvement in decisions about treatment, and discussions about treatment options and recommendations6. The main approach to achieving true shared decision making is coaching clinicians to encourage the client's self-efficacy, reflect on the client's expressed choices, and help him/her weigh the pros and cons of his/her options. The clinician-client dynamic changes from one of clinician as director to assistant or facilitator. We urge clinicians to use collaborative language (“we” , “us” , “let's work this problem together” , “we could try this”) and to avoid verbal dominance (i.e., when clinician or client gives a monologue rather than sharing an equal dialogue) to convey a shared responsibility and power in the relationship. When discussing treatment decisions or interpretations of behaviors or events, clinicians should recognize that presenting their opinions with certainty or relaying factual medical assertions can disempower clients. Therefore, clinicians should express their ideas with humility (“Maybe another way could be…”; “I don't know if I am right about this, but another possibility…”). This allows clients to accept, reject or modify the clinician's ideas while the clinician is receptive to the client's perspective. Our second lesson is to center treatment goals on what is important to the client, based on his/her expressed concerns7 (“How do you understand your problem?” , “What does this problem represent to you?” “What do you think is causing this problem?”). In trials with ethnic minority populations, we begin every session by asking clients what they want to focus on, so that the content of the session, including exercises and skill building, is tailored to the clients’ immediate concerns. Using a client's language in framing the problem aids both clinician and client in experiencing the problem through the client's eyes. For example, when a client states that he feels disgust for himself when using drugs, the clinician reminds him that he has previously stated that drugs help him feel confident and stable, and reframes his use of drugs as a potentially unhealthy coping tool when dealing with difficult circumstances. In pediatric mental health practices, one mistake that can impede focus on the client's concerns is concentrating on generational hierarchies, or only asking the parents about what they see as the problem, bypassing the child's perspective. Clinicians should address children directly and ask about their concerns. This approach seeks to share a common view of the problem, directed by the client's experience. Our third lesson for clinicians is to be willing to explain to clients who they are, share with clients some of their social identity, and ask clients to do the same. During a clinical encounter, for example, the clinician can share something he/she enjoys doing or dreamed about when moving to the US. In turn, the clinician may ask the client questions to magnify the importance of the client's social identity (“Do you want talk about your tattoos and what they represent, as you previously commented?”). These exchanges can facilitate learning about the clients’ cultural, interpersonal or social worldview and attempted coping mechanisms that can shed light on how they comprehend their problems and what might be acceptable solutions. These strategies may also help clinicians avoid attribution errors and build trust based on a joint understanding of what words, behaviors or actions might mean. We acknowledge that barriers to engagement in mental health care for minority populations, as well as for the clinician who treats them, may be attitudinal or structural in nature. These are barriers that require substantial cognitive efforts by clinicians to overcome and that require longer visits in resource poor environments where most of these populations are served. Some attitudinal barriers that interfere with engagement are stigma, bias, prejudice, and racial/ethnic discrimination1, 2, 8. Some structural barriers that might also influence engagement include linguistic obstacles in communicating, limited availability of times for care, and poor quality of services1, 2, 8. Furthermore, individual factors (e.g., socioeconomic status, self-efficacy, health literacy), organizational factors (e.g., policies and practices), and societal factors (e.g., social and community norms) interact to influence engagement in services9. Efforts to improve engagement in mental health care need to address both attitudinal and structural barriers. Clinicians can adopt these engagement recommendations in their individual practices, but systemic changes are needed to solidify these strategies in mental health care settings. Systemic changes include incorporating engagement activities into clinician training and treatment protocols, offering flexible service delivery modes (e.g., by phone or within non-clinical settings), and integrating mental health care management to address social determinants of health. Engaging ethnic minority clients requires clinicians to construct the clinical encounter with egalitarian collaboration that addresses the clients’ needs, empowers their decision making, and amplifies their voice in treatment.