Community mental health services for the underserved: A culturally specific model

Community Mental Health Services for the Underserved: A Culturally

Specific Model Josepha Campinha-Bacote

Underutlliiation of community mental health services by minorities has been an ongoing concern in the field of mental health. Many agencies are mainstream and ethnocentric in their services to culturally diverse clients, resultlng in color- blind treatment approaches. During the era of civil rights, the concept of differ-

ence was used to exclude groups of individuals, families, and communities from access to resources. However, ethniclty does matter and make a difference. This article will address the need for culturally relevant services for Afiican- American clients with the dual diagnosis of substance abuse and mental illness. The intent is to provide mental health care providers with a culturally specific model that will render culturally relevant and culturally competent services to indiiduals from diverse cultural backgrounds. Copyright 0 1991 by W.B. Saunders Company

U NDERUTILIZATION of mental health ser-

vices by minorities continues to pose a prob-

lem for community mental health centers. The Na-

tional Institute of Mental Health ([NIMH]

Bethesda, MD) shares this concern. In 1981, NIMH sponsored a review of the Community Sup-

port Programs for mental health services, with a

special emphasis on minorities. The results of this

review demonstrated the need to “develop model

programs and clinical treatment standards that

were culturally and ethnically appropriate” (Mar-

tin, 1988, p. 1). This article describes one program and the es-

sential components necessary to deliver culturally relevant mental health services to African-

American clients. The need for such a program was stimulated by the findings of the Ohio Depart-

ment of Mental Health’s “Report of the Minority Concerns Committee,” which stated: “The find-

ings of this report reflect the chronic inequalities

inherent in the current system of state mental

health services for Ohio’s minority population.

The remediation process must provide for the cre- ation of culturally sensitive services if minorities and their communities are to accept and use the services” (Fleming, 1988, p. 1). If the nursing profession begins to implement culturally specific

nursing interventions for specific ethnic/cultural

groups, not only will there be increased knowledge

for the field of transcultural nursing, but possible solutions to the issue of underutilization of mental

health services by minorities also will be ad-

dressed. The intent of this article is to describe the

components of a culturally specific program in a

community mental health center in southwestern

Ohio.

CONCEPTUAL FRAMEWORKS

Leininger’s (1978) Transcultural Nursing The-

ory and Sue’s (1977) Models of Service Delivery

and Outcome will be used as the conceptual frame-

works for this article. Leininger’s theory offers a

nursing perspective on the issue of culturally specific care, while Sue’s model addresses the issue of

From the College of Nursing, Ohio State University, Co- lumbus; and the College of Nursing and Health, Univer- sity of Cincinnati, OH.

Address reprint requests to Josepha Campinha-Bacote, Ph.D., R.N., C.S., C.T.N., 921 Oregon Trail, Wyoming, OH 45215.

Copyright 0 1991 by W.B. Saunders Company 0883-9417/91l0504-0oof5$03.00/0

Archives of Psychiatric Nursing, Vol. V, No. 4 (August), 1991: pp. 229-235 229

230 JOSEPHA CAMPINHA-BACOTE

community mental health services to minority groups. Leininger (1978, p. 33) states:

[Transcultural nursing theory] refers to a set of interrelated crosscultural nursing concepts and hypotheses which take into account individual and group caring, behaviors, values, beliefs based upon their cultural needs, in order to provide effective and satisfying nursing care to people, and if such nursing practices fail to recognize cuhurolog- ical aspects of human needs, there will be signs of less efficacious nursing care practices and some unfavorable consequences to those serviced.

Transcultural nursing theory has its origin in the field of anthropology, which recognizes the impor- tance of using knowledge derived from a person’s world view and way of life. The emit and etic views are central concepts in the theory of transcultural nursing. The emit view is concerned with the local perceptions and cognition about a specific phenomenon, while the etic view refers to the universal aspects of knowledge domains about a specific phenomenon (Leininger, 1978). An emit (or native) view is essential for providing culturally specific inventions because many health care professionals are ethnocentric in their beliefs about health care practices and treatments. Transcultural nursing theory is based on the premise that cultures should be able to determine the extent and type of care they receive from professional caregivers, and that the perspective, knowledge, and experience of the culture are crucial factors to consider in assessing, planning, and implementing nursing care.

Figure 1 depicts Sue’s Models of Service Deliv- ery and Outcome (Sue, 1977). The first model as- sumes that the type of client (ethnic group/client) receives differential treatment, which results in a poor outcome. Sue asserts that in this case, ethnic clients receive different or poorer services and,

DIFFERENTIAL TREATMENT

/

(2) GOOD OUTCOME

(1)

<

POOR OUTCOME

TYPE OF CLIENT <

\

(3)

<

POOR OUTCOME

EQUAL TREATMENT

(4) GOOD OUTCOME

Fig 1. Models of service delivery and outcome. IReprinted with permission [Sue, 19771. Copyright 0 1977 by the Amw-

icen Psychological Aasocietion.1

therefore, poorer outcome. The second model as- sumes that ethnic clients, by virtue of their cultural background, require different (culturally specific) services in order to facilitate a good outcome. This model is intended to provide a fit between treatment technique and client’s life-style rather than differences that are discriminatory and therapeuti- cally inferior (model 1). Model 3 reflects a minority client who receives nondiscriminatory (equal) treatment, but the outcome is unfavorable because of the poor fit between treatment and the client’s cultural background. The last model (model 4) raises the possibility that equal services may be effective for some ethnic groups. Sue (1977) spec- ulates that these clients have life-styles that are similar to those of other mainstream Americans. Sue contends that (1) we may reach a point where service modalities are equal but unresponsive to ethnic clients, (2) the adequacy of services to minority groups is an extremely complicated issue, and (3) our efforts should be aimed at specifying the conditions that foster favorable outcomes.

A CULTURALLY SPECIFIC PROGRAM FOR

AFRICAN-AMERICANS WITH A DUAL DIAGNOSIS

The greatest challenge to nurses is to provide culturally relevant services for culturally diverse groups, individuals, and communities. The author was challenged to develop and implement a culturally specific treatment program for African- Americans with a dual diagnosis of substance abuse and mental illness (SAMI). This culturally specific program, located in southwest Ohio, is at a university-based community mental health clinic. Fifty African-American clients constitute the program’s client base. Approximately 70% of these clients are men and 30% are women. The two most common psychiatric diagnoses repre- sented in this client population are schizophrenia (80%) and bipolar affective disorder (10%). Co- caine abuse and alcohol dependence are the two most common drugs of abuse in this client population. These clients range in age between 20 and 40 years. Forty percent of these clients are home- less and reside in an economically deprived area of an inner city. This university-based clinic has an existing traditional program for SAM1 clients, but it was unable to attract minority clients, necessi- tating the need for a culturally specific program. The author interviewed SAM1 clients from the culturally specific SAM1 program and SAMI clients

COMMUNITY MENTAL HEALTH SERVICES 231

from the existing traditional SAM1 program in order to examine the perceived differences between the two programs. The author also interviewed the staff of the two SAM1 programs to ascertain their perceived differences between a culturally specific (nontraditional) and traditional SAM1 program. The author’s descriptive study found seven major differences: (1) frameworks used, (2) environmen- tal factors, (3) need for parallel treatment, (4) need for rediagnosis, (5) biological/genetic considerations, (6) focus on expressive arts, and (7) need for comprehensive health services.

FRAMEWORKS USED

The traditional SAMI program used Bennett’s (1983) model for the dual-problem client. Bennett views the dual problem as cyclical in nature. The client is caught in a cycle of substance abuse that relieves symptoms of psychopathology in the short run but exacerbates the symptoms in the long run (Fig 2). Interventions at any point in the cycle serve to break the maladaptive pattern and offer alternative coping behaviors. Similarly, the culturally specific SAM1 program used Bennett’s model, but with one addition: Interventions in this model were culturally specific, i.e., used the world views of the African-American culture, including their positive beliefs and values and distinct problem- solving styles.

The culturally specific program also used the culturally specific frameworks of Bell (1981) and Phillips (1988). Bell’s model of black interper- sonal styles allowed the therapists to avoid seeing African-Americans as a monolithic group of people with the same values, goals, beliefs, and ideas. Bell described acculturated, culturally immersed, bicultural, and traditional interactional styles of African-Americans. The use of this model was es-

/mikik:::~ Temporary “high” feeling

or getting a “buzz” Obtaimng substance

1

\ Desire for alcohol

Psychological or emotional crisis and or unprescribed

and/or not taking prescribed substances

psychotropic medication ?

‘L Lack of adequate

Discomfort, dysphoria coping skills

w re&

Fig 2. The dual-problem client. Reprinted with permission from Bennett et al., 1983. Delmar Publishers, inc., Copyright 1983.

sential in assessing the appropriateness of an individual for a culturally specific program. The acculturated African-Americans were referred to the traditional SAM1 program due to their interactional style. Specifically, “the acculturated black person has made conscious or subconscious decisions to reject the general attitudes, behaviors, customs and rituals associated with being black. He/she has done this in order to assimilate into the mainstream white culture” (Bell, 1981). It seems clear than an acculturated African-American client would not benefit from a culturally specific program.

Phillips’s NTU psychotherapy (1988) provided the program with culturally specific interventions based on a Afrocentric world view. NTU is an African word for the cosmic universal force man- ifested in all life and things (Phillips, 1988). One goal of NTU therapy is to help people and systems become authentic and balanced within a shared en- ergy and essence that is in alignment with the natural order (Phillips, 1988). Phillips adds that good mental health springs from being in harmony with the natural order and that healing is, therefore, a natural process. NTU psychotherapy is spiritually based and asserts that there is a spiritual force to all life and that the spiritual dimension is the link to the mental and physical spheres of humankind. Phillips identifies harmony, balance, interconnect- edness, cultural awareness, affective epistemology, and authenticity as the core principles of an- cient and Afrocentric world view.

The other goal of NTU psychotherapy is to help the client system function within the guidelines of Nguzo Saba, the seven principles of Kwanzaa: (1) Umoja (unity), (2) Kujechagulia (self-deter- mination), (3) Ujima (collective work and respon- sibility), (4) Ujamaa (cooperative economics), (5) Nia (purpose), (6) Kuumba (creativity), and (7) Imani (faith) (Phillips, 1988). These two goals provided the framework for the culturally specific interventions used in the SAMI program. Ethno- music therapy is a culturally specific intervention based on the NTU psychotherapy concept of affective epistemology. (See section entitled, Focus on Expressive Arts).

ENVIRONMENT

The SAMI clients in the culturally specific program commented that the therapists’ offices “felt like home. ” They said that the pictures on the wall and background music were familiar. The clients


were referring to posters reflecting African- American families, pictures of Martin Luther King, Jr., and other African-American leaders, as well as African-American poets and musicians. In contrast, the traditional SAM1 clients commented that they felt uncomfortable on one occasion when they had to use the author’s office for a group session. They specifically stated that the office was “depressing” and “too black.” Although environment may initially be viewed as a superficial variable of a culturally specific program, it has the potential, when used with other culturally specific interventions, to allow the client a safe, homelike environment.

FOCUS ON THE EXPRESSIVE ARTS

Traditional group therapy sessions and psychoanalytic approaches used in the traditional SAMI program had little relevance to the African- American client. The need to focus on the expressive arts was evident in the culturally specific SAM1 program. Ethnomusic therapy is one ap- proach that reflects an expressive arts orientation and is based on NTU psychotherapy. Ethnomusi- cology is music that “considers world music genres in relationship to their cultural contents and has the potential to (1) enhance musical and inter- personal communication for clients of a specific ethnic background, and (2) motivate otherwise unresponsive mainstream music therapy clients into musical experiences that are culturally relevant (Moreno, 1988). The culturally specific SAM1 program used ethnomusic therapy as a treatment modality.

Ethnomusic therapy uses the Afrocentric princi- ple of affective epistemology. Affective epistemology is the process and belief system of a people discovering knowledge and truth through feeling or emotion (Phillips, 1988). Specific Cultural Arts Therapy (SCAT) was one technique developed by the culturally specific SAM1 program. SCAT refers to the deliberate use of blues music as a treatment modality to assist African-American with their SAM1 problems (Campinha-Bacote 8z All- bright, 1990). Goines (1973) stated that blues music developed as a simple and inexpensive form of therapy for African-Americans. The majority of blues music deal with situations and problems about which African-Americans feel a sense of helplessness and confusion (Goines, 1973). The blues express real emotions, and singing of or lis-

tening to blues lyrics can be an effective release of emotions for the African-American client. The culturally specific SAM1 program found it necessary to use ethnic music as a therapeutic intervention because it has the potential to reach the client on the deepest possible level of culture, values, and a shared world view (Moreno, 1988).

BIOLOGICAL AND GENETIC CONSIDERATIONS

There is a paucity of research in the area of ethnicity and biological responses. The culturally specific SAM1 program showed that young Afri- can-American males had more extrapyramidal symptoms (as measured by the Abnormal Involun- tary Movement Scale [Department of Health, Ed- ucation, and Welfare; Washington, DC]) when placed on haloperidol decanoate (haloperidol in- jection). This finding places the young African- American male at high risk for developing neuro- leptic malignant syndrome. In contrast, the traditional SAM1 program did not report any sta- tistically significant findings in relation to haloperidol decanoate and the incidence of extrapyramidal symptoms. Ethnicity and its impact on psychopharmacology is a valid concern for culturally specific programs. Lefley (1990) reported that ethnic differences in response to psychotropic medica- tions have been under review for more than a de- cade. There are studies confirming extrapyramidal effects at lower dosage levels in specific ethnic groups, such as Asian-Americans (Lawson, 1986).

PARALLEL TREATMENT

The traditional SAM1 program clients had little difficulty in following through with referrals to the clinic. However, the African-American SAM1 clients demonstrated low compliance in following through with referrals to the clinic. The author de- fines noncompliance to treatment as the failure of the health care provider to provide culturally specific interventions. When a client does not engage in a program, the health care provider must review whether or not the program is respecting and in- corporating the client’s cultural belief system. The culturally specific SAM1 program found it necessary to go into the state mental hospitals and inpatient psychiatric facilities to recruit and motivate clients to engage in this outpatient program. The clients were allowed to attend the outpatient culturally specific SAMI program for 2 days each week during their hospital stay (parallel


treatment). This culturally specific intervention increased the following through of referrals to the clinic.

REDIAGNOSIS

National statistics report that African-Americans are diagnosed more often as having more severe thoughts disorders, as compared with European- Americans, who are diagnosed more as having more affective disorders. Statistics from Ohio state hospitals for fiscal year 1984 showed these current trends: For blacks, the percentage of admissions to state psychiatric hospitals is three times greater than their percentage representation in the total state population (i.e., 29.6% and 9.9%, respec- tively); in addition, 63% of unduplicated admissions of blacks resulted in severe diagnosis (i.e., schizophrenia or schizophrenic-related) as compared with 43% for whites (Report of the Minority Concerns Committee, 1988).

It was necessary for the therapists in the culturally specific program to conduct a culturological assessment of each client to reassess their initial diagnosis. The therapists found that in 40% of the cases, the diagnoses were incorrect. Specifically, schizophrenia was overdiagnosed and misdiag- nosed in the African-American population. This finding is consistent with Adebimpe (1981) who asserted that because blacks experience hallucinations unrelated to schizophrenia, they are misdiag- nosed as schizophrenics. The culturally specific SAMI therapists rediagnosed most African- American schizophrenics as having a bipolar affective disorder. This rediagnosis is consistent with the works of Mukherjoe, Shukla, and Woodle (1983), who reported that blacks with affective disorders exhibit hallucinations and delusions more frequently than whites. Accurate diagnosis is critical for planning appropriate treatment approaches.

COMPREHENSIVE HEALTH SERVICES

The traditional SAMI program focused exclusively on substance abuse and mental illness, while the culturally specific SAMI program discovered the need to look beyond mental health services. The African-American clients were using the mental health clinic for all their needs. The therapists developed groups that focused on morbidity and mortality factors relevant to African-Americans. One example was the implementation of a humor

group to deal with the problems of hypertension and stress in the African-American culture. Humor has been noted to elicit specific physiological effects (Fry, 1979). Laughter relaxes the abdominal muscles, diaphragm, neck, shoulders, and inter- costal muscles and, therefore, can be used as an intervention for stress management (Fry, 1979). Laughter also enhances the cardiovascular system. There is an increase in systolic and diastolic blood pressure. The amount of increase in blood pressure is proportional to the duration and intensity of the laughter, with a drop in pressure below the baseline after the laughter episode (Fry, 1979). This physiological effect of a drop in pressure below the baseline has the potential of being an effective technique to deal with the issue of essential hypertension in the African-American population. In addition to the humor group, the program dealt with other morbidity factors in the African-American population such as low birth weights and a higher incidence of deaths in infants. Group discussions (for example, of substance abuse and pregnancy) and humor groups were all part of the program’s culturally specific way of dealing with the issue of comprehensive health services.

CONCLUSION

There are several explanations as to why minorities do not use community mental health centers. There is also a disparity in the use of mental health services by minorities. One possible explanation that may contribute to the underuse of mental health services is the traditional, mainstream, Eu- rocentric focus of many existing agencies. Many agencies lack culturally specific services that are critical to the delivery of effective treatment for clients with the dual diagnosis of chronic mental illness and substance abuse. The goal of a cultur-

ally specific model is to provide culturally respon-

sive services to specific cultural groups that are

compatible and congruent with that ethnic group’s world view. The basis for the effectiveness of a

culturally specific model is that the cultural group

is able to determine the extent and type of care they

receive from professional caregivers, and that the

culture’s viewpoint, knowledge, and experience

are crucial factors to consider when providing nursing care (Leininger, 1978).

Flaskerud ( 1984) stated that the individual’s per- ception of the problem and its management are crucial in providing effective and safe care to in-


Table 1. Similarities and Differences Between a Traditional SAM Program and a Culturally Specific SAM Program

Traditional

Uses Bennett’s (1983) conceptual model of the “dual-

problem client”

Uses group and individual therapy with a Western

orientation (i.e., psychoanalytic)

Treatment focuses exclusively on the dual diagnosis (i.e.,

SAMI)

Physical environment does not play a critical factor in

treatment

Culturally Specific

Uses a modified version of Bennett’s (1983) conceptual

model in addition to the culturally specific models of

Phillip’s (1988) and Bell (1981)

Uses group and individual therapy from a Afrocentric

orientation (i.e., ethnomusic therapy, humor therapy)

Treatment focuses not only on the dual diagnosis problem,

but considers the total health needs of the client, (i.e.,

morbidity or mortality issues of African-Americans)

Physical environment plays an important factor in treatment

to reflect the client’s cultural background [i.e., African-

American pictures and symbols present)

Therapist accepts the client’s presenting diagnosis (no need

for rediagnosis or conducting of a culturological

assessment)

Biological and genetic responses to medication are not an

issue

Referrals are obtained through telephone contact and

appointments that are set up by inpatient programs at

hospital discharge

Due to misdiagnosis of minorities, there is an essential need

to rediagnose the client by completing a culturological

assessment

Need to consider biological and genetic responses to

medication (i.e., higher incidence of extrapyramidal

symptoms in young black males on haloperidol; ethnicity

and psychopharmacology is important)

Referrals are obtained by focusing on the establishment of

personal contact and a close relationship with the client

while he or she is in an inpatient setting (i.e., client

attends an inpatient treatment program while also

attending the outpatient culturally specific SAMI program)

dividuals of different cultural backgrounds. She further added than ai emit view of behavior would provide health, care professionals with culturally compatible explanations of behavior as well as culturally compatible interventions of managing behavior. (Flaskerud, 1984, p. 192). The articulation of culturally specific interventions that are effective with specific ethnic groups will assist mental health care professionals in attaining culturally compatible interventions. Leininger (1978, p. 141) takes the strong position that “a nurse should not be viewed as professional until she can effectively work with people in at least a bicultural setting, and the professional nurse should be prepared to respond effectively to people in our pluralistic world as an essential criterion of being professional.” As nurses, we must be challenged to critically examine our responses in effectively working and caring for individuals from culturally diverse backgrounds. One strategy to meet this challenge is to articulate specific interventions that are culturally relevant with specific ethnic groups. The culturally specific SAMI program for African- Americans in southwest Ohio is one attempt to meet this challenge. The major differences in a nontraditional (culturally specific) and tra-

ditional SAMI program are summarized in Ta- ble 1.

REFERENCES

Adebimpe, V.R. (1981). Overview: White norms and psychiatric diagnosis of black patients. American Journal of Psychiatry, 138, 279-285.

Bell, P. (1981). Counseling the black client. Alcohol use and nbuse in black America. Center City, MN: Hazelden.

Bennett, G., Vourakis, C., & Woolf, D. (1983). Substance abuse: Pharmacological, developmental and clinical perspectives. New York, NY: Wiley.

Campinha-Bacote, J., & Allbright, J. (1990). Ethnomusic therapy and the dual-diagnosed African American client. Manuscript submitted for publication.

Department of Health, Education, and Welfare. (1974). Ab- normal Involuntary Movement Scale (AIMS). Washing- ton, DC: Author.

Flaskerud, J. (1984). A comparison of perceptions of problem- atic behavior of six minority group and mental health professionals. Nursing Research, 33(4), 190-197.

Fleming, B. (1988). Report of the minor@ concerns committee. Columbus, OH: Ohio Department of Mental Health.

Fry, W. (1979). Humor and the human cardiovascular system. In H. Mindness & J. Turek (Eds.), The study of humor. Los Angeles, CA: Antioch.

Goines, L. (1973). The blues as black therapy. Black World, 23(l), 28-40.


Leininger, M. (1978). Transculturat nursing: Concepts, theo- ries, and practices. New York, NY: Wiley.

Lawson, W.B. (1986). Racial and ethnic factors in psychiatric research. Hospital and Community Psychiatry, 37, 50- 54.

Lefley, H. (1990). Culture and chronic mental illness. Hospital and Community Psychiatry, 41(3), 277-286.

Lin, K., Poland, R.E., & Lesser, I.M. (1986). Ethnicity and psychopharmacology. Culture, Medicine, and Psychia- try, 10, 151-165.

Martin, M. (1988). Differences fotm the basis for inclusion. Community Support Network News, 4(4), 1-2.

Moreno, J. (1988). Multicultural music therapy: The world connection. Journal of Music Therapy, 25(l), 17-27.

Mukhergee, S., Shuklal, S., Jr Woodle, J. (1983). Misdiagno- sis of schizophrenia in bipolar patients: A multi-ethnic comparison. American Journal of Psychiatry, 140. 1571-1574.

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Community mental health services for the underserved: A culturally specific model