Problems in designing and implementing culturally relevant mental health services for Latinos in the U.S

PROBLEMS IN DESIGNING AND IMPLEMENTING CULTURALLY RELEVANT MENTAL HEALTH

SERVICES FOR LATINOS IN THE U.S.

MOISES GAVIRIA and GWEN STERN Department of Psychiatry. Abraham Lincoln School of Medicine. University of Illinois.

912 South Wood Street, Chicago, IL 60612, U.S.A.

Abstract-Passage of the Community Mental Health Centers Act in 1963 by the U.S. Congress reflected a new concern with providing mental health services to previously underserved communities, many of them minority communities in the inner cities, and a new goal of primary prevention through social change. It has been assumed that utilization by non-white. non-middle class patients will increase when services are “culturally relevant”. One group which has consistently underutilized mental health services is Latinos, who comprise the second largest-and fastest growing-minority in the U.S. Three constituencies active in planning mental health services for Latin0 populations are: (1) governmental funding agencies. (2) social scientists, and (3) Latin0 activists. They have each approached the issue of cultural relevance in mental health service delivery from different perspectives: governmental funding agencies stressed geographic proximity to services; social scientists pointed out the need to recognize indigenous, folk belief systems and practitioners; Latin0 activists saw the key to cultural relevance in staffing patterns providing bilingual. bicultural staff. While many would uncritically accept these assumptions, the three constituencies involved in planning and delivering mental health services have frequently clashed and actual changes in service delivery have been difficult to implement. A case study which illustrates the difficulty of implementing-and defining-culturally relevant services in a Mexican/Chi- cano community mental health center is presented. Directions for future research to develop and evaluate culture-specific treatment modalities are suggested.

INTRODUCTION

The Community Mental Health Centers Act of 1963 was passed in a unique historical context, at a time when the Civil Rights Movement was promoting the idea of social justice, revived ethnic pride among minorities, and basic social change in the U.S. In addition, President Kennedy had a deep personal interest in mental health, and campaigned on a plat- form of increased services to the mentally ill.

Passage of the Community Mental Health Centers Act by the U.S. Congress signaled a departure from traditional psychiatric treatment, calling for a broader spectrum of services-which were to include inpatient, outpatient, emergency services. consultation and education-and for increased access to services for a wider range of people [l]. There was to be a new concern for primary prevention reflecting the belief that community mental health included basic change and alteration of the socio-economic and structural factors believed to contribute to poor mental health [2]. There was also to be increased access to services through location of services in geographic proximity to previously underserved minorities, especially Blacks and Latinos.

The terms “Latino” and “Hispanic” are used to refer to the Spanish speaking populations in the U.S., which constitute the country’s second largest minority with a population of I I.2 million. It is estimated that by the year 2000 Latinos will be the largest minority group in the U.S. with a population of 55.3 million, due to a high fertility and steady immigration from Mexico and Puerto Rico.

For political and funding purposes. there is little distinction made between the Mexican. Puerto Rican.

Cuban, and South American groups which are lumped together as “Latinos”; in the paper we use the more global term “Latino” in discussing culturally relevant services to the Spanish speaking in general. Of the groups subsumed under the designation of Latino, the largest is an estimated 6.6 million of Mexi- can descent. Population figures do not include the roughly 67.4 million undocumented workers, the majority of whom are also from Mexico [3]. The case study presented here deals with a specifically Mexican population; the term “Chicano” is used to indicate people of Mexican descent who have been in the U.S. for more than one generation and follows popular usage in the community to distinguish recency of arrival from Mexico.

Despite the intentions of the Community Mental Health Centers Act to increase access to services among minorities, a major theme in the literature on mental health in Latin0 populations has been that services are consistently underutilized. A number of factors are presumed to account for underutilization, among them :

1. Culturally based differences in the perception and interpretation of mental illness so that only severe pathology is presented for treatment [4].

2. Use of alternative mental health resources such as “folk healers”, priests, and general practitioners [S-IO].

3. Lack of accessibility to appropriate mental health services due to linguistic. class. cultural and institutional barriers [I I].

Whatever theory is used to account for underutilization of mental health services-at least institution-

c.s!.l 14 IN , 65

66 MOISES GAVIRIA and GWEN STEW

aiized services-by Latinos. there is general agreement that ability to communicate in Spanish is an important factor in increasing utilization. Beyond this, however, there has been little agreement about what other components contribute to making services “culturally relevant”. and actual changes in either the content or style of services have been difficult. The following paper discusses some of the difficulties in defining cultural relevance and in implementing changes in the service delivery system to the Latin0 population.

The case history of a community mental health center in the Midwest illustrates the impact of shifting funding priorities on service delivery models. and the difficulty of translating theories about culturally reie- vant services into actual practice.

We focus on three constituencies whose perspectives on culturally relevant services have changed and sometimes clashed over the years since 1963, but which have had direct effect on the deveiopment of community mental health centers such as the Chicano Mental Health Center described in the case study. These constituencies are identified as:

A. Governmental funding agencies. B. Social scientists. C. Latin0 Community Activists.

THE MANY MEANINGS OF CULTURAL RELEVANCE

The federal and state mental health agencies

The concept of “cultural relevance” was not specifically defined or mandated in the Community Mental Health Centers Act. The intent was to increase accessibility to services by:

1. Locating them in communiti~ to assure physical accessibility;

2. Mandating education~onsultation services and community organizing efforts as preventive components within CMHC’s;

3. Using paraprofessional staff who could “relate” to patients and provide social services; and

4. Ensuring community input through mandatory community advisory boards.

The notion of “catchment areas” was developed to ensure that services would be physically accessible to a defined population, and that centers would become identified with specific communities. Manpower programs, such as the New Careers Program, were designed to provide a pool of trained paraprof~sionais, who could theoretically communicate and “relate” better to patients from the communities and of shared ethnicity.

While the initial policy stateqlent in the form of the Community Mental Health Centers Act contained some novel approaches to cultural relevance. e.g. physical accessibility. community boards, and paraprofessional staff. the initial focus of the Act quickly dissipated. Community activists soon demanded a “piece of the action” in the form of jobs, support for community organizing efforts and community control of the new mental health services. Professional mental health workers were confused by the sudden change in traditional roles and the focus on social change rather than individual psychopathology. Ail these

pressures contributed to a rapid “retrenchment”:

Amid these fierce buffetings. the CMHC’s gradually moved towards the more traditional activities of individual and small-group care and consultation on request. Optimistic forecasts ol what community psychiatry could do for social reform in the “total community” declined. as did the claims made for the Great Society programs as a whole. Justifica- tion for the CMHC programs shifted from social reorgani- zation to the’ provision of customary services to alleviate individual deprivation and illness [ZJ.

Gradually, the “education and prevention” goals of the Community Mental Health Centers Act became diluted by the increasing attention given by funding agencies to the goal of community-based “after-care” for deinstitutionaiized mental patients. With the end of the original 8-year federal funding for community mental health centers, there was a move to concen- trate on special populations, defined by pathology rather than ethnicity or social class. With this new approach to funding, cultural relevance became irreie- vant.

Social scienrists: ~ni~r~~~~~~ and cross-cuitl~rul psychiatry

Recent studies in Medical Anthropology and Cross-Cultural Psychiatry have identified important ways in which cultural and social factors affect mental health status and treatment, and have provided ethnographic data on mental health issues in Latin0 populations. These studies have emphasized the importance of:

1. Folk healers and their role in the delivery of services [IZ. 131.

2. Belief systems regarding mental illness and expectations about treatment (14161.

3. Accuitu~ation and its impact on the mentat health of ethnic communities [ 17. IS].

4. The emotional support derived from the extended family in Latin0 populations [ 19.201.

5. Ethnic differences in psychopathology [22]. 6. The identification of culture-bound syndromes

[23,24-J

Specific recommendations for culturally relevant mental health services have focused on the incorporation of folk healers. or indigenous curers. into the mental health delivery system. Such healers include curanderos. espiritistus and sameros.

According to anthropological reports. the appeal of folk healers is that healer and client share a similar belief system regarding the etiology of emotional ili- ness (usually based on supernatural factors) and its treatment. Folk healers tend to view emotional illness in a social and religious context rather than as a strictly biological event.

In sum. the academic community stressed the importance of taking advantage of indigenous healers, becoming aware of culturally defined systems of dis- ease etiology and treatment, and evaluating behavior symptomatic of mental illness in a cultural as well as a medical-psychiatric context.

The cofn~unity activists

The emphasis on social change and paraprof~sionai workers threatened both professional roles and tradi-

tionai territories. Many professionals felt uncomfort- able with these new, nonclinical goals. Controversy persisted around such issues as what credentials were necessary and what the proper roles of professionals and paraprofessionals were within the CMHC’s.

The concept of community-based services had sud- denly created a third constituency: Latin0 community activists. For activists, cultural relevance was often equated directly with a lack of the professional training which had produced mental health “experts” who were too removed from community problems. For community activists, cultural relevance clearly hinged on staffing patterns, and would naturally emerge if the staff was Latino, bilingual, and familiar with community problems. Training was thought to be less important in delivering services than was intuitive “street knowledge”.

population was young, spoke primarily Spanish, and worked as unskilled labor or in small retail busi- nesses. The remaining Middle-Europeans were elderly and many still spoke their native languages of Polish, Lithuanian, and Czech. They were retired, and were gradually following their adult children to the western suburbs.

Today, this community can be described demographically as Mexican and Chicano, low income (aver- age: ~8~/yr.), young (SO”/, of the population is under 18 years of age), with large families, and Spanish as the predominant language. There is a thriving retail business of restaurants, taverns, and other stores offering a wide range of traditional Mexican foods, clothing, and religious items. Of the 500,000 Latinos in Chicago, 1 IO,00 are located in this community and it is the largest Latin0 barrio in the midwest.

Ail of the interpretations and strategies outlined above-those of the federal policy makers, the social scientists, and the community activists-reflect innovative approaches to designing culturally relevant mental health services. Yet it has proved difficult to actually implement changes in service delivery and even more difficult to evaluate what contributes to “culturally relevant” services.

The following case history illustrates some of the contradictions in the definitions of culturally relevant services, and the difficulty of effecting changes in programs due to the shifting priorities of the mental health system.

A case history: The Chicano Mental Health Center (CMHC)

At the beginning of the program, staff from the in-patient psychiatric facility in the medical complex were shifted out to comprise the staff of the outpost. A Chicano Director for the CMHC was hired, but the clinical staff was composed of Anglo females. Some paraprofessional slots were filled with Chicanos from the community who began doing the organizing and out-reach functions described in the guidelines of the Act. However, the patients using the CMHC mirrored the ethnic make-up of the staff, since the clinic staff could not communicate with Spanish speaking residents in the community, they retreated into delivering traditional psychiatric services to a population of elderly, and chronically ill, Middle-Europeans who had been deinstitutionaiized into the community [25].

In 1966, a program was designed jointly by various university and state mental health institutions at the nearby medical complex, and funded by the National Institute of Mental Health under the 8-year funding guidelines of the I963 Act. The grant proposed to offer inpatient and specialized psychiatric services at the medical complex, and to place three outposts within a catchment area which included Mexican, Middle-European. and Black communities. The Chi- cano Mental Health Center (CMHC) was the “Mexi- can Outpost” in the catchment area.

The goals of this proposal specifically addressed the issues of cultural relevance, and reflected the new spirit-of the Community Mental Health Centers Act. They included :

Gradually, Anglo staff members who left were re- placed with Latinos and the patient population soon changed to reflect the new ethnic makeup of the staff. In 1973, a New Careers program geared to recruiting and training Chicanos in mental health fields was developed by activists, aimed at deveIoping skills in such areas as counseling while emphasizing the importance of cultural relevance to the delivery of non- traditional mental health services. Many of the paraprofessional staff of the CMHC went through this program and went on to continue their education. Thus, the CMHC has operated as a career ladder for its Chicano staff, but in the process lost the benefits from their training.

( 1) Involving co~unity residents in decision-making for the project,

Another interesting aspect of the CMHC and its search for “cultural relevance” is the fact that there was anthropological input through a Community Research Unit staffed by a team of applied anthropologists.

(2) Facilitating community organization as a preventative activity, and

(3) Providing culturally relevant care to the non- white. non-middle class residents of the catchment area.

The goal of culturally relevant services “. . . was strongly related to the assumption that social and cultural factors played a key role in the childbearing process and in adult personality functioning” [25].

In 1967 when the CMHC was established, the community in which it was iocated was rapidly becoming predominantly Mexican after a long history of suc- cessive Middle-Eurovean oonulations. The Mexican

Yet, their data had little impact on actual service dehvery and there were inter-disciplinary communication problems from the beginning: clinical staff did not see ethnographic information as helpful to them in day-to-day practice. A basic problem, as the theme of this paper suggests, was the gap between ethnographic data and the actual implementation of programs and treatment styles to reflect this information. There was always a gap between the paraprofessional staff interested in preventive programs, and the ciini- cai staff who took a more narrowly psychiatric view of treatment. The inability of the anthropological team to bridge this gap is in part due to unresolved differences about the mission of the mental health __ center as well as the proper role of the mental health

Culturally relevant mental health services for Latinos in the U.S. 67

68 Morsrs GAWRIA and GWEN STERN

worker-differences which are not unique to the CMHC [27]. The result was that while attempts at communication with the clinical staff declined, the anthropologists became active with the paraprofessional staff and administration of the CMHC in community action efforts. Consistent with the social change goals of the original legislation, the CMHC provided “consultation and education” to a number of community groups attempting to begin programs. The anthropologists collected epidemiological, demographic, and ethnographic data which-along with the staff support, phones, desks, and oflice supplies provided by the CMHC-helped in the funding of other preventive mental health programs such as a polydrug abuse program for youth and a rehabilitation program for heroin addicts.

In 1975. the federal funds ran out. The CMHC formed a separate corporation to secure continued funding at the state level from the Illinois Department of Mental Health (IDMH).

With IDMH funding, program priorities were forced ‘to change drastically: there were no longer monies for prevention nor consultation and education. The emphasis and sole priority of the state was Clinical Services and more specifically, after-care. Accordingly. paraprofessiona1 slots were eliminated and new clinical programs such as a Day Treatment Program, and Sheltered Workshop were developed to meet the rehabilitation needs of chronically ill patients.

The emphasis ‘on after-care is an example of how funding priorities ignore the epidemiological needs of the community to be served, and jeopardize the concept of culturally relevant services. Clearly, in a population that is demographically young, poor. poorly educated. and has recently undergone the stress of migration and culture shock. after-care is not the most pressing mentat health issue. Special needs in this young. Mexican community include crisis inter- vention and case work, perinatal health care, alcoholism and drug programs, counseling and social service programs for children and adolescents, and services for patients who are in the U.S., illegally and fear deportation. Yet. despite the epidemiological needs in the community, state funding currently restricts 75% of CMHC budget to the after-care program which serves a population of 200 chronically ill. schizo- phrenic patients. 40”/, of whom are Anglo.

Over the past IO years, certain facets of the CMHC have developed on the assumption that they will result in culturally relevant services: the hiring of bilingual, Latin0 staff, the participation of the anthropologists and other staff in community action efforts, and the development of local paraprofessional staff through a New Careers program. However, there has been little change in actual treatment modalities: the services of the CMHC as funded by the Illinois De- partment of Mental Health are limited to traditional, out-patient, after-care and workshop.

Some of the contradictions inherent in the theories of cultural relevance put forth by the three constituencies-the governmental funding agencies. the social scientists. and the activists-as well as some of the ditbculties in translating theories of cultural relevance into actual culture-specific treatment modalities merit discussion.

DISCL’SSION

Gooernmental fimdiny oyrncies

Part of the difficulty in defining culturally relevant services for Latin0 populations lies in the basically incompatible goals of the Community Mental Health Centers Act of 1963 which calls for: (I) preventative programs which would alleviate potential environ- mental hazards to general mental health, and (2) chni- cal out-patient programs which were to allow for the deinstitutionalization of chronically ill patients into the community [26].

The task of long-term treatment of deinstitutiona- Iized patients was (and is) a monumental task. calling for specific clinical skills and medical interventions. The task of “improving the mental health of communities” is also a monumental task, calling for a staff with different skills. The relative priority of each of these goals was never clarified.

Federal and state funding agencies quickly aban- doned the goal of social change (via “consultation and education” funds) and retreated into the more traditional preoccupation with clinical after-care which had repercussions for staffing patterns as well as program activities and design. The change in orientation from prevention to clinical services also changed the “popuIation to be served” from being the total community to being only those individuals exhibiting a specific pathology.

Social scientists

The anthropologists and cross-cultural psychiatrists, have also had little impact on the implementation of innovative services.

Medical anthropologists have.. talked a great deal about the role of cultural and community variables in service provision. Most frequently this discussion has taken the form of documentation of the survival of traditional folk medical systems which continue to be salient as alterna- tives to American health care. The message to medieat per- sonnel is that they must be UWWY of such alternative medi- cai systems. However. this information production while identifying the need for culturally relevant services provides little help in determining how such services should be organized [27].

One concrete suggestion made by anthropologists has been to incorporate folk healers-curandrros. espiritistas. santeros-as mental health resources for Latin0 patients. Recommendations have focused on how the folk healers can interact with staff of the mental-health center as auxilliary therapists or as part of a mutual referral network. In our opinion. these suggestions have ignored the lack of data on the actual rates of use of folk healers in urban Latin0 populations and for what types of problems they are used [4,2S]. As Pattison points out, it has become fashion- able to talk of developing working relationships between scientifically oriented psychotherapists and folk healers without clearly delineating what that relationship should consist of, and how differences in world- view will be overcome [29].

Recommendations to incorporate folk healers into the mental health system to increase the “relevancy” of those services for a Latin0 population overlook another factor: self-selection by patients. it is perhaps not realistic to expect individuals with alternative


belief systems to use the mental health system- whether there is a curandero on staff or not-any more than it would be realistic to expect a patient who has indicated his belief in “scientific” medicine by coming to a mental health center to be satisfied with a referral to a folk practitioner [cf. 93.

Lurifro community activists

The third constituency, Latin0 activists, have consistently emphasized the importance of staffing patterns in delivering culturally relevant services. They see the presence of bilingual, bicultural staff as a mini- mum requirement for increasing utilization of mental health services by Latin0 patients. The history of the CMHC supports this position. e.g. the patient population tended to mirror the ethnicity of the staff, becoming more Latin0 as the staff became more Latino.

It is generally agreed that therapy is most effective when provided in the primary language of both patient and therapist [30]. Research suggests that diagnosis is affected by a lack of linguistic match between patient and therapist, with the therapist tend- ing to see more psychopathology if predominant language is not shared [31,32-J.

In the sixties, activists called for the hiring of “community-based” paraprofessionals, insisting that their very lack of professional training made them able to “relate” to patients. One study. by the Group for the Advancement of Psychiatry, attempted to distinguish what was special about paraprofessional workers in a more objective fashion. It cuggested that paraprofessionals in general are more proficient “in the realm of practical activity” than professionals, and that the “know-how” of survival is a very real skill which should be studied and incorporated into the training of professionals [33].

Six factors were identified by paraprofessionals as contributing to their ability to establish a closer alliance with patients:

I. Emphathetic feeling for the patient’s experiences. 2. Sense of geographic continuity resulting from

both working and living in the community. 3. A feeling that they had themselves lived through

the stresses being experienced by patients. 4. A conviction that their past life experiences had

trained them well for their work in mental-health. 5. Greater flexibility and mobility in meeting with

the patient than traditionally trained persons. 6. Ease of verbal communication in terms of

language use and language style.

This assessment suggests that in addition to shared language, experiential background (of which social class is certainly one aspect) provides specific skills- empathy, flexibility, and verbal facility-which contribute to relevant services. Recently, it has been suggested elsewhere that social class match is an important component in the communication between patient and therapist, and that lack of class’ match colors diagnosis, recommendations to treatment modalities. and therapeutic communication [ 11,30, 34,353. Skills in diagnosis based on understanding of the patient’s social situation, and flexibility of treatment approach based on experiential and/or class match between patient and therapist are two specific areas that merit further study.

Community activists have consistently stressed the importance of having not only bilingual staff but bicultural staff. Ethnicity is Seen as a crucial component in interpreting “deviant” behavior and in providing patients with an appropriate treatment technique based on shared cultural beliefs and understanding. Yet within the U.S. ethnicity is by no means an objective criterion. Calls for an “ethnic match” between patient and therapist have ignored the subtle- ties of defining “ethnicity”, the problems of correlat- ing ethnicity with belief systems, and the historical, cultural and generational heterogeneity of the Latin0 populations in the U.S. Recent recommendations have urged more research and recognition of the heterogeneity of Latin0 populations in the U.S., and the incorporation of these differences into mental health planning [36,37-J.

Most Latin0 mental health professionals in the U.S. do not ethnically match their patients: most have im- migrated from Latin American countries and may have little knowledge of the socio-economic context of Latinos born in the U.S. For example, while the staff of the CMHC is largely Latino, the majority of workers are from Latin American countries: only two reflect the specifically Mexican background of community residents. Martinez (1977) cites statistics com- piled by Ruiz on the status of Latinos in the Ameri- can Psychiatric Association and notes that out of the 3.44% of psychiatrists who are Spanish-surnamed. only 0.54% were U.S. residents. Only 43 psychiatrists nationwide are Chicano [38].

Culture-specific treatment modalities: Current research

As we have seen in the example of the CMHC, locating a center geographically in a community, and providing Latin0 staff, is not synonymous with implementing new models of treatment. The lack of implementation of new, culture-specific treatment modalities in general, and specifically at the CMHC, is a result in part of constantly shifting.funding priorities and guidelines, as well as difficulty in applying ethnographic or cultural data to the actual design of culture specific service programs in the mental health system.

In recent years, a number of papers emanating from the Spanish Speaking Mental Health Research Center have suggested some models and directions for developing’ culture-specific modalities [3941]. These suggestions focus on modalities which (1) incorporate the family in the treatment process and (2) include access to comprehensive social services.

Padilla, Ruiz and Alvarez [49] discuss the “family adaptation model” as a therapeutic model in which family-centered therapy would be offered, perhaps in a home-like setting, and in which the traditional roles of the Latin0 family might be acknowledged in the therapeutic process or actually reenacted by the therapist. Others suggest that the reliance on the family as a support system indicates a mode of inter- action based on personal rather than status relationships. To build on this “culture style”, the style of the relationship between patient and therapist should change to reflect the importance of personalismo in Latin0 culture [36].

The recommendations of the Special Populations Sub-Task Panel on the Mental Health of Hispanic Americans combine a number of these concepts and

70 MOISES GAVIRIA and GWEN STERN

propose Cernros Fan&ares which would be multi-ser- health services have basically retreated to a physical vice centers providing social services as well as or geographic approach to defining accessibility and psychotherapy, where therapeutic relationships would cultural relevance: It is assumed that if services are be “highly personalized”, and where the family would physically located in a community. that they will be be serviced as a .whole [37]. accessible. and thus “relevant”.

While there is disagreement on what kinds of programs and approaches are more appropriate, there is agreement that the existing mental health system does not meet the mental health needs of Latin0 patients or communities. In part, this conclusion is based on the low rate of utilization of these services by Latinos. In addition, as was noted by the President’s Commis- sion on Mental Health: “There is considerable clinical evidence that many of the treatment techniques com- monly used in hospital settings and community mental health centers are not effective with Hispanic clients”. A basic problem in assessing this situation is the lack of evaluative research data based on the experiences of the community mental health centers era. The commission cites the great need for research on the appropriateness and eficacy of different treatment modalities developed for Hispanics in general as well as specific subpopulations such as Hispanic women, children, and the elderly [37].

The constituencies involved in procidiuy mental health services for Latinos have basically relied on a staffing approach to defining accessibility and cultural relevance: it is assumed that patient population will reflect the ethnic/linguistic composition of staff and that Latin0 staff will deliver culturally relevant services almost by definition.

In addition to the need for evaluative program research, there is a lack of current research on Latin0 mental health issues. Existing research tends to assume cultural homogeneity, creates stereotypes, stresses the exotic, and makes simplistic cross-cultural comparisons based on univariate analyses [37]. For example, we have very little information on the epi- demiology of alcoholism in Latin0 populations, the cultural aspects of drinking behavior, or the response to alcoholism treatment programs among Latin0 alcoholics. Because of the capriciousness of funding policies and a limited world-view about what constitutes mental health, there has been little program- matic change within the U.S. mental health system in the last decade. In short, there are few examples of innovative programs to evaluate, and as Padilla, Ruiz, and Alvarez note:

Since the enactment of the Community Mental Health Centers Act of 1963. perspectives on cultural relevance have frequently clashed, compounded by ambiguity about professional/paraprofessional roles within the mental health system and about the mission of community mental health in general. The case history of the Latin0 Mental Health Center was presented to illustrate the difficulty of actually implementing changes in service modalities within the mental health system due to the inability to utilize ethnographic data, shifting funding policies which ignore local epidemiological needs, the specific demography

of Latinos working in the mental health system. conflicts over the clinical vs. the activist role of mental health workers. and the goals of community mental health.

What is needed now is the investment of research monies and energy to elucidate concepts of cultural relevance and develop demonstration programs within the various Latin0 communities, cognizant of their heterogeneity.

REFERENCES

I.

A recommendation for “innovative” treatment programs is self-defeating unless validating research is conducted. Even more critically. demographic and survey research is needed to guide the development of programs with the greatest probability of success [42].

In summary, many writers have stressed the impor-

tance of culturally relevant services, usually defining this in terms of shared language, class, culture, and belief systems. But we have not moved much beyond the rhetoric of the community mental health centers movement of the 1960’s in documenting bow or t$ these are the critical factors.

6.

Summury

The constituencies responsible for planning and implementing community mental health programs for Latin0 populations have had differing interpretations of what constitutes “culturally relevant” services. Three constituencies have been identified-the governmental funding agencies, the social scientists, and the community activists-which have had a major impact on the development of mental health programs for Latinos.

7.

8.

9.

I 0. The constituencies involved in findiny mental

Kennedy .l. F. Message from the President of the United States Relative to Mental Illness and Mental Retardation. Document 58, 86th Congress, Feb. 5. 1963. p. 12. Musto D. Whatever happened to community mental health? fsychiut. /tini. 7. 10. 1977. Macias R. F. U.S. Hispanics in 2000 A.D.-projecting the number. Agenda 3, 16. 1977. Barrera M. Mexican American mental health service utilization. Commun. Mmr. Hlth J. 14, 35, 1978. Edgerton R. B., Karno M. and Fernandez I. Curdnder- ismo in the metropolis. the diminished role of folk psychiatry among Los Angeles Mexican-Americans. Am. J. Psychorhrr. 24. 124. 1970. Padilla A. M.. Carlos M. L. and Keefe S. E. Mental health service utilization by Mexican-Americans. In Psychotherapy with fhe Spun&h Speakirlg Issues iu Research und Srrvicr Delivery (Edited by Miranda). Monograph No. 3. Spanish-Soeakina Health .Research Center. U’CLA, Los Angeles, California. 1978. Torrey E. F. The case of the indiaenous therapist. Archs-yen. Psychiat. 20. 375. 1969. - Ayala F. Folk practices, folk medicine and C’uruuder- ismo on the west side of Chicago. Paper presented at the Annuul Mretbq of the Socierv /i)r Applied Atlthro- poloqy. Miami, 1972. Schensul S. L.. Bymel M. B. and Ayala F. Cultural and community factors in health service delivery: A case from a Chicago Chicano community. Unpublished manuscript, 1977. Velosa L. H. The importance of a community mental health center in a Spanish-speaking community. In


Il.

12.

13.

14.

15.

16.

17.

18.

19

20.

21.

22.

23.

24.

25.

26.

27.

28.

Trunscultural Psychiatry: An Hispanic Perspective, Etc. (Edited by Padilla and Padiiia). pp. 55-61. Spanish- Speaking Mental Health Research Center, UCLA, Los Angeles. California. 1977. Padiiia A. M., Ruiz R. and Alvarez R. Delivery of community mental health services to the Spanish-speaking/ surnamed population. In Delivery of ServiceJor Larino Community Mental Health (Edited by Alvarez R.). pp. I l-39, Monograph No. 2. Spanish Speaking Mental Health Research and Development Program. UCLA. Los Angeles, California 1975. Rogier L. H. and Hoihngshead A. The Puerto Rican spiritualist as a psychiatrist. Am. J. Sociof. 67. 17, 1961. Roman0 J. J. Charismatic medicine, folk healing and folk sainthood. Am. Ant/nap. 67, 1151, 1965. Karno M. and Edgerton R. B. Perception of mental illness in a Mexican American community. Archs gen. Psychiat. 20. 233. 1969. Fitzgibbons D. J.. Colter R. and Cohen J. Parent’s self perceived treatment needs and their relationship to background variables. J. consult. c/in. Psycho!. 37. 253, 1971. Gaviria M. and Wintrob R. Supernatural influence in ~ychopathology. Can. psychiat. Ass. J. 21. 361, 1976. Graves T. D. A~cuituration access and alcohol in a tri-ethnic community. Am. Anrhrop. 69, 306, 1967.

Madsen W. Value conflicts and folk psychiatry in South Texas. In Maaic Faith and Heaiina (Edited bv Kiev A.). Free Press,New York, 1964. ” - Femandez M. R., Maidonado Sierra E. D. and Trent R. D. Three basic themes in Mexican and Puerto Rican Family values. J. sot. Psychiat. 48, 167, 1959. Diaz G. R. Neurosis and the Mexican family structure. Am. J. Psychiat. 112. 411, 1955. Maidonado Sierra E. D.. Trent R. D. and Fernandez M. R. Neurosis and traditional family beliefs. Int. J. sot. Psychiat. 7, 237, 1960. Fabrega H., Swartz J. D. and Wallace C. A. Ethnic differences in psychopathology Il. Specific differences with emphasis on the Mexican American Group. Psy- &at. Res. 7, 221, 1968. Fernandez M. R. The Puerto Rican syndrome: Its dynamics and cultural determinants. Psychiurry 24, 79, 1961. Pattison E. M. and Eipers J. A. A developmental view of mental health manpower trends. Paper presented to Fifth World Congress of Psychiatry, Mexico City, November, 1971. Gaviria M., Vasquez A., Hoigin P., Gentile M. and Tirado 1. A community mental health program for the Spanish-Speaking population in Chicago: Eight years of evolution. In Transcultural Psychiatry: An Hispanic

Perspective (Edited by Padiila and Padilla), pp. 35-43. Monograph No. 4, Spanish-Speaking Mental. Health Research Center, UCLA, Los Angeles, California, 1977. Borus J. F. Issues critical to the survival of community mental health. In Am. J. Psychtar. 135. 1029, 1978. Schensui S. L. Two community mental health programs: A comparative analysis. Paper presented at the Meetings of the American Psychological Association, Chicago, 1975. Aiegria D., Guerra E., Marine2 C. and Meyer G. G. El hospital invisible, a study of curanderisma. Archs gen. Psychiat. 34, 1354. 1977.

29.

30.

31.

32.

33.

34.

35.

36.

37.

38.

39.

40.

41.

42.

Pattison E. M. Psychosocial interpretations of exor- cism. J. operat. Psychiat. 8, 5, 1977.

Torrey E. F. The Mind Game. Emerson Ha!!, New York 1972. Abad V., Ramos J. and Boyce E. Clinical issues in the psychiatric treatment of Puerto Ricans. In Transcul- rural Psychiatry: An Hispanic Perspective (Edited by Padiila and Padiila), pp, 25-34, Monograph No. 4. Spanish-Speaking Mental Health Research Center. UCLA. Los Angeles, California. 1977. Miller S. 0. Current status of Hispanic social workers. In Hispanic Mental Heaith Pro~e~~anals (Edited by Oimedo and Lopezj. Spanish-Speaking Mental Health Research Center, UCLA, Los Angeles, California, 1977. The Community Worker: A Response to Human Need, Vol. 9. Report, No. 91. The Committee on Therapeutic Care, Group for the Advancement of Psychiatry, New York, New York, 1974. Abad V., Ramos J. and Boyce E. A model for delivery of mental health services to Spanish-Speaking minorities. Am. J. Orthopsychiat. 44.584, 1974. -

Acosta F. X. Mexican American and Anglo American reactions to ethnically similar and dissi&ar psycho- therapies. In Delivery of Services for Latin0 Com~unfry Mental ~ea~rh (Edited by R. Alvarez). pp. 51-78, Monograph No. 2. Spanish-Snaking Mental Health Research and Development Program. UCLA, Los Angeles. California. t 975. Alvarez R. et 01. Latin0 Community Mental Health. Latin0 Task Force on Community Mental Health Training. Monograph No. I, Spanish-Speaking Mental Health Research and Development Program, UCLA, Los Angeles, California. 1974. Report -on the President’s Commission on Mental Health. By the Special Population Sub-Task Force on Mental Health of Hispanic Americans. Reprinted by the Spanish-Speaking Mental Health Researcher Center, UCLA, Los Aneeies. California 1978. Martinez C. Hispanics ii psychiatry. In Hispanic Men-

tal Health Prufessi~a~ (Edited by Olmedo. and Lopez), pp. 7-13. Monograph No. 5. Sp~ish-Snaking Mental HeaIth ,Research Center, UCLA, Los Angeles. California, 1977. Castro F. G. Leuel of Acculturation and Related Con-

siderations in Psychotherapy with Spanish-Speaking/ Surnamed Clients. Occasional Paper No. 3, Spanish- Speaking Mental Health Research Center, UCLA, Los Angeles, California, 1977. Ruiz R.. Casas J. M. and Padilia A. M. Cultural/y Rele- vant Behavioristic Counseling. Occasional Paper No. 5. Spanish-Speaking Mental Health Research Center. UCLA, Los Angeles, California, 1977. Miranda M. R. Psychotherapy with the Spanish-Speak- ing: Issues in Research and Service Belivery. Mono- graph No. 3, Spanish-S~king Mental Health Research Center, UCLA, Los Angeles. California. 1976. Padilia A. M., Ruiz R. A. and Alvarez R. Delivery of Community Mental Health Services to the Spanish- Speaking/Surnamed Population. In Delivery of Services for Latino Community Mental Health (Edited bv Alvarez R.), Monograph ed. No. 2. Spanish-Speaking Mental Health Center. UCLA. Los Angeles. California.

Documents

Problems in designing and implementing culturally relevant mental health services for Latinos in the U.S