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date: 25 April 2019

Cultural Competency in Mental-Health Services

Abstract and Keywords

Since the 1980s, cultural competency has increasingly been recognized as a salient factor in the helping process, which requires social-work professionals to effectively integrate cultural knowledge and sensitivity with skills. This entry chronicles the history of mental-health services and the development of cultural competency in social-work practice, followed by a discussion of mental-health services utilization and barriers to services among racial/ethnic minorities. Directions for enhancing cultural competency in mental-health services are also highlighted.

Keywords: cultural competency, ethnicity, mental health, minorities, race, social work


Cultural competence has been recognized as one of the most challenging movements in the field of mental health (Sue, 2006). Cultural competence has gained considerable attention among mental-health professionals and organizations concerned with providing services to an increasingly diverse clientele (Wendt & Gone, 2012). This attention has typically been attributed to the changing social, political, and economic climate, along with increasing numbers of racial and ethnic minority and immigrant populations in the United States. According to the U.S. Census Bureau (2010), although the non-Hispanic White population remains the largest major racial/ethnic group, it is also growing at the slowest rate. In contrast, the populations of Hispanic/Latinos and Asians have grown considerably, in part because of relatively high levels of immigration. Between 2000 and 2010, the Hispanic/Latino population grew by 43%, from 35.3 million in 2000 to 50.5 million in 2010, and this population accounted for more than half of the 27.3 million increase in the total population. The changing population presents a number of issues with regard to mental-health services for diverse racial and ethnic groups.

Cultural competence has emerged as a foundation for social-work education and practices in pluralistic societies such as the United States and is considered an essential element in promoting effective mental-health services to all populations (Allen-Meares, 2007; Weaver, 1999). The ability to provide mental-health care to diverse populations is a standing ethical commitment in the social-work profession, which provides the bulk of mental-health services in the United States (National Association of Social Workers [NASW], 2012). Regrettably, persistent mental-health disparities have been widely observed and effective practical solutions for addressing such disparities remain elusive (Wendt & Gone, 2012). One major issue concerning the delivery of mental-health services is how to make them more culturally responsive to diverse populations (Whaley & Davis, 2007).

Historical Overview of Mental-Health Services

During the 18th and 19th centuries, mentally ill patients were commonly placed in asylums, which were for the most part staffed by untrained personnel with no professional experience in providing treatment for mentally ill individuals. Patients residing in asylums were referred to as inmates, and standards of care for mentally ill patients did not exist; as a result, they were often neglected and mistreated. In the 19th century, the term psychiatry was coined, which defined mental-health care and treatment, and the state began to assume responsibility for the care and treatment of mental illness by building and maintaining asylums and institutions. When the Civil War ended and abolition of slavery followed suit, it was predicted that there would be an increasing need for institutions to accommodate those who suffered from postslavery stress disorder (Davis, 1997). Data from the 1840 census indicated that the frequency of mental illness was significantly higher for free Northern Blacks than for slaves in the South (Thomas, A., & Sillen, 1972). State-managed asylums and institutions were furthered by Dorothea Dix in the 1840s and resulted in the passage of the New York State Care Act in 1890 (Trattner, 1994). Under this act, the state of New York assumed care of the insane poor population, and other states followed with similar legislation.

In 1907, standards of care for nurses working with mentally ill patients were established, and in 1913, the Johns Hopkins Hospital School established training for psychiatric nurses. Regrettably, there was a major dearth of mental-health facilities in the 1920s (Trattner, 1994), and the existing facilities were overcrowded and in deplorable condition, prompting social workers to carry on major campaigns to remedy the situation. Consequently, states began providing additional funds to build more institutions to provide treatment for mentally ill patients (Trattner, 1994). In the 1930s, there was a major change in the treatment of mentally ill patients with the exploration of new standards of care such as insulin and electroshock therapy. Doctors oversaw care given by mental-health nurses rather than untrained personnel. For the most part, the focus of mental-health treatment was primarily on individuals who suffered from severe and chronic mental illness (Grob, 1992), and mental-health care, including electroconvulsive therapy, psychosurgery, and psychotherapy, was primarily based in hospitals (Dana, 1998). When World War II came to an end, there was still an important need for further progress in the field of mental health, which required more and better trained psychiatrists, hospitals, and new methods of treatment. In 1946, the National Mental Health Act was signed into law by President Harry S. Truman. The act provided federal funding for research to examine the causes, treatment, and prevention of mental illness (Freedman, 1967). Widespread public demand existed for reformation of the existing mental-health services and dismantling of state hospitals.

It was not until the 1960s, however, when the civil rights movement influenced the social and political landscape of the United States, that a decentralized system of mental-health services was established and services no longer focused on severe mental illness. In addition, groundbreaking research in psychiatry highlighted the importance of understanding socioeconomic factors in the cause and treatment of mental illness, suggesting that effective treatment necessitates socially supportive, community-based programs in lieu of institutions (Trattner, 1994). Interestingly, the common view that African Americans and immigrants were susceptible to mental illness because of their higher likelihood of poverty, life stress, and urban migration was a factor leading to President Kennedy’s successful rationale for the legislation that established community mental-health centers (Davis, 1997). In 1963, the Community Mental Health Centers Act (Pub. L. No. 88–164) was signed by President John F. Kennedy (National Institutes of Health, 1963). The act was characterized as the most dynamic revolution in the history of mental-health treatment and signified the beginning of a national attempt at culturally relevant mental-health service delivery to racial and ethnic minorities (Cheung & Snowden, 1990). Characterized as deinstitutionalization, the responsibility for mentally ill patients shifted to psychiatric units in general hospitals, private psychiatric institutions, community-care programs, and other types of residential facilities (Mechanic, 1998). Deinstitutionalization was attributed to the development of more effective psychotropic medications in the 1950s, which made it possible to manage illness without hospitalization, and the availability of Medicare and Medicaid for care in residential settings (for example, nursing homes; Korr & Ford, 2003). However, deinstitutionalization was also characterized as ineffective because of a high relapse rate resulting from inadequate outpatient care and a low rate of medical compliance (Korr & Ford, 2003). These failures contributed substantially to the increasing rate of homelessness in the United States.

By the 1970s, mental-health professionals were advocating for federal government involvement in addressing the problems in continuity of care and the lack of integration between community mental-health centers and state hospitals (Mowbray & Holter, 2002). In 1975, the federal government enacted the Public Health Service Act (Pub. L. No. 94–63), which included three requirements with regard to quality assurance in community mental-health centers: development of national standards for the centers, development of quality-assurance programs, and data collection for program evaluation (Towery & Windle, 1978). This act was amended numerous times and was made a permanent part of the Public Health Service Act in 2010. According to this act, health and mental-health centers are required to operate in or serve underserved communities and populations (for example, racial/ethnic minorities; The Henry J. Kaiser Family Foundation, 2012). Social workers also comprised one quarter of full-time employees in community mental-health centers (Morris, 1974), which allowed them to observe and document the failure of deinstitutionalization (Mowbray & Holter, 2002). Regrettably, social workers were not adequately trained to provide services to individuals with serious mental illness, and their negative perceptions of disabled clients had adverse effects on the quality of service delivery (Segal, 1970). In response, in 1978 the federal government created the Community Support Program, which proposed a new system of care and support for individuals with chronic mental illness. The emphasis of the program was to facilitate the adaptation of seriously mentally ill patients to community living (Turner & TenHoor, 1978), which consisted of crisis services, psychosocial rehabilitation, supportive living and working arrangements, medical care, and case management (Mowbray & Holter, 2002). The program also sought to make former patients, consumers, and family members viable stakeholders in service delivery, and funding support for consumer-operated activities increased. Despite the major advances in mental-health services, there was a serious dearth of funding for culturally appropriate treatment for racial and ethnic minorities, and federal funding was mainly used to train primary-care physicians rather than psychiatrists (Dana, 1998). Racial and ethnic minorities, most notably African Americans, were less likely to receive adequate services and care than Whites, but the expectations of African Americans for equitable mental-health services were raised by the civil rights movement. Mental-health service utilization had been relatively low among African Americans, who often relied on family members or church ministers before seeking emergency care for serious mental distress (Dana, 1998).

In the mid-1970s, consensus existed among interest groups that the mental health–care system was in need of reform. Lobbying on the part of special interest groups and a commitment of President Jimmy Carter led to the passage of the progressive Mental Health System Act (Thomas, A. R., 1998). Under the administration of President Ronald Reagan, however, the focus shifted toward the cost, financing, and reimbursement of services, as well as reducing federal spending and creating a favorable business climate. Under the Reagan administration, the act was rescinded, and mental-health policy was left almost entirely to the provision of individual states (Thomas, 1998). African American perceptions of mental-health services also began to change in the 1980s when service providers were acceptable to most African American clients (Gary, 1987). Many African American clients with an Afrocentric identity believe that racism is a primary factor in mental distress and prefer an African American service provider who may share their beliefs and can provide treatment for the effects of racism and other related concerns (Helms, 1990).

In the late 1980s, managed-care organizations also began to proliferate and contract with states to provide mental-health services to Medicaid beneficiaries (Institute for the Study of Health Care Organizations & Transactions, 2000). Combined with the focus on community support services in the 1960s and 1970s and psychiatric rehabilitation in the 1980s, this laid the foundation for a new vision of service delivery for the mentally ill in the 1990s, which was guided by the recovery model (Anthony, 1993). State hospitals began to close, and the number of hospitals, which had remained constant at 300 since about 1955, dropped to slightly over 40 in the 1990s. More state-controlled mental-health funding was allocated to community care than to state institutions by 1993 (Koyanagi & Bazelon, 2007). By 1999, the Surgeon General had issued the Report on mental health, which documented the efficacy of mental-health services with regard to the wide range of treatments available. An important supplement to the Surgeon General’s report, Mental health: Culture, race, and ethnicity (U.S. Department of Health and Human Services [USDHHS], 2001), examined disparities and considered barriers to treatment at the individual and system levels. At about the same time, the Institute of Medicine’s report, Unequal treatment (Smedley, Stith, & Nelson, 2002) noted problems with both access and quality of medical and psychiatric treatment for minority patients.

Mental Health and Service Utilization of Racial and Ethnic Minorities

Since the 1980s, there has been growing concern among mental health–care professionals and researchers about differential treatment outcomes for racial and ethnic minority clients (Larrison et al., 2004). Recent research revealed that all of the subgroups of racial and ethnic minorities reported lower rates of lifetime mental illnesses than Whites reported (see McGuire & Miranda, 2008). A review of research by Samaan (1998) on the influence of race, ethnicity, and poverty on the mental health of children also reported that after controlling for socioeconomic status, African American, Native American, and Latino/Hispanic children are less likely to report or be reported to have mental-health problems than White children. Theoretically, cultural experiences (for example, religiosity) can buffer against psychological distress among racial and ethnic minorities (Samaan, 1998). For instance, religion has traditionally been identified as a key protective mechanism for African Americans (see Levin, Chatters, & Taylor, 2005; Taylor, Ellison, Chatters, Levin, & Lincoln, 2000; van Olphen et al., 2003). Despite the lower reporting of mental illness among Hispanic/Latinos and African Americans compared with Whites, racial and ethnic minorities with mental illness were more likely to have more persistent illness (Breslau et al., 2006). Further, although African Americans were less likely to have major depression than Whites residing in similar areas (Breslau et al., 2006), African Americans were more likely to rate their depression as very severe and disabling (Williams et al., 2007). Moreover, a limited number of studies on Mexican Americans indicate that mental-health problems such as depression are greater among immigrants than among the general population (see Padilla, 1997).

Disparities in access and quality in health and mental-health services and treatment outcomes among racial and ethnic minorities have also been well documented (Greeno, 2008; Lasser, Himmelstein, Woolhandler, McCormick, & Bor, 2002; National Institute of Mental Health, 2007, 2010). Findings from several studies suggest that racial and ethnic minorities are significantly less likely to utilize or receive mental-health services than Whites (for example, Carson, 2011; Coker et al., 2009; Cummings & Druss, 2011; Garland et al., 2005; Hatzenbuehler, Keyes, Narrow, Grant, & Hasin, 2008). For instance, the National Survey of Black Americans, designed to assess how symptoms of distress are defined and responded to by African Americans, reported that the majority of African Americans did not seek mental-health services in response to emotional disorders (Neighbors et al., 2007). Lasser and colleagues (2002) also found from a nationally representative sample that Hispanic/Latinos and African Americans had lower rates of visit for drug therapy and talk therapy (that is, counseling or psychotherapy) than Whites in both primary-care and psychiatric settings. Such disparities may exist because of less trust between clients and health-care providers, language and cultural barriers, problems of treatment and retention of racial and ethnic minorities, overdiagnosis of schizophrenia among African Americans and depression among Latinos, high rates of substance-use disorder and suicide among Native Americans, lack of health insurance, and clinical bias among nonminority service providers (Atdjian & Vega, 2005; DeNavas-Walt, Proctor, & Lee, 2005; Dobalian & Rivers, 2007; Dulmus & Roberts, 2008; Lasser et al., 2002).

Understanding Cultural Competence in Mental-Health Services

Cultural Competence

The most challenging aspect of cultural competence in mental-health practice is the lack of a collectively agreed-upon definition and operationalization that comprehensively and accurately captures the essence of the construct (Ridley, Baker, & Hill, 2001). Earlier researchers (for example, Green, 1982) defined cultural competence as the ability to provide services that are consistent with the culture of the client, which necessitates the practitioners’ ability to modify their professional tasks and work styles to adapt to the cultural values of the client. Ridley and colleagues (2001) argued that such a definition is insufficient because it does not provide practitioners with enough information to carry out “cultural competence.” Rather, the desired outcomes and steps needed to achieve competence must be set forth (Ridley et al., 2001). In response, Betancourt, Green, Carrillo, and Ananeh-Firempong (2003) expanded the traditional definition of cultural competence by emphasizing “the importance of culture, assessment of cross-cultural relations, vigilance toward the dynamics that result from cultural differences, expansion of cultural knowledge, and adaptation of services to meet culturally unique needs” (p. 294). A more recent definition provided by Bhui, Warfa, Edonya, McKenzie, and Bhugra (2007), which was derived from a synthesis of the key characteristics, posits that cultural competence is “a set of skills or processes that enable mental health professionals to provide services that are culturally appropriate for the diverse populations that they serve” (p. 4). The definition focused primarily on how culture shapes attitudes, expressions of distress, and help-seeking practices (Bhui et al., 2007).

The definition of cultural diversity and cultural competence in social work has primarily been associated with race and ethnicity, but diversity is taking on a broader meaning to include the sociocultural experiences of people of different gender, class, religious beliefs, sexual orientation, age, and physical/mental abilities.

The NASW Code of Ethics, approved in 1996, delineated cultural competence as an ethical responsibility of social workers toward clients (see 1.05 Cultural Competence and Social Diversity):

  1. 1. Social workers should understand culture and its function in human behavior and society, recognizing the strengths that exist in all cultures.

  2. 2. Social workers should have a knowledge base of their clients’ cultures and be able to demonstrate competence in the provision of services that are sensitive to clients’ cultures and to differences among people and cultural groups.

  3. 3. Social workers should obtain education about and seek to understand the nature of social diversity and oppression with respect to race, ethnicity, national origin, color, sex, sexual orientation, gender identity or expression, age, marital status, political belief, religion, immigration status, and mental or physical disability.

This was further clarified in 2008:

  • Social workers should obtain education about and seek to understand the nature of social diversity and oppression with respect to race, ethnicity, national origin, color, sex, sexual orientation, gender identity or expression, age, marital status, political belief, religion, immigration status, and mental or physical disability.

Cultural competence in social work practice and services “implies a heightened consciousness of how clients experience their uniqueness and deal with their differences and similarities within a larger social context” (NASW, 2001, p. 8). Indicators for achievement of the cultural competence standards were issued in 2007 (NASW, 2007).

Barriers to Cultural Competency in Mental-Health Services

To better understand the importance of cultural competence in mental-health services, we should first explicate what is meant by culture. According to Oyserman and Lee, culture is defined “as a set of structures and institutions, values, traditions, and ways of engaging with the social and nonsocial world that are transmitted across generations in a certain time and place… that is, cultural is both temporally continuous and specific” (p. 255). Culture is best understood as a multidimensional rather than a single construct because conflation of race, ethnicity, country, or national origin with a single construct of culture can be misleading (Oyserman & Sorensen, 2009). Culture as a single, unitary construct can falsely create a sense that societies do not socialize for multiple, potentially contradictory cultural component sets or syndromes, which might be cued by various situations (Oyserman & Sorensen, 2009, p. 27). Moreover, viewing culture as a single construct can reduce the likelihood of seeing commonalities between syndromes in one society or set of societies and other seemingly dissimilar societies (Oyserman & Sorensen, 2009, p. 27). Similarly, race and ethnicity are constructs that have been commonly used by others and are considered fixed, whether or not one chooses to self-identify with them (Oyserman, Kemmelmeier, Fryberg, Brosh, & Hart-Johnson, 2003). Indeed, racial and ethnic minorities are frequent targets of stereotypes and discrimination based on their cultural identity, which can affect their mental-health status and the likelihood of receiving services. Cultural context, which refers to social environments such as family, school, and community, can also invariably affect the behavior and cognition of an individual. Racial, ethnic, and cultural identities also influence how the self is defined, how interpersonal relationships are imagined, what is of value and worth, and how the mind operates (Oyserman & Lee,).

Mental disorders or psychopathologies, such as depression and schizophrenia, often overlap with other DSM disorders with culture-bound syndromes, and their forms of expression in symptoms and syndromes differ across racial and ethnic groups because they can signify moral, religious, political, and social crises (Fabrega, 1991). Therefore, understanding these disorders and providing culturally competent mental-health services necessitate identification using cultural formations (Dana, 1998). Some of the most commonly identified barriers that may impede mental-health services utilization across racially and ethnically diverse populations are help-seeking behavior (and lack thereof), mistrust, and clinical bias and misdiagnosis.

Help-seeking behavior.

As previously mentioned, various reasons exist as to why racial and ethnic minority clients do not seek out and receive mental-health services as frequently as White clients. For instance, Asian Americans and Pacific Islanders have been frequently identified as low utilizers of mental-health services. The low rate of utilization might reflect a low rate of mental-health problems among Asian Americans and Pacific Islanders. However, when examined more closely, mental-illness conditions are significantly more severe and chronic among Asian Americans than among other racial and ethnic groups. Findings from the study of Abe-Kim et al. (2007), which included a nationally representative sample, indicated that Asian Americans had lower rates of mental health–related service use and were less likely to seek help than the general population. According to Leong and Lau (2001), several reasons exist, such as cognitive barriers (for example, lack of culturally informed conceptions of mental illness shared by Asian American subgroups), affective barriers (for example, feelings of shame and stigma), value-orientation barriers (for example, conflict between cultural values and values inherent in the Western mental-health system), and physical barriers (for example, clients’ lack of awareness of available services and their inability to access services because of geographic location). Other reasons for underutilization of mental-health services across Asian American subgroups include a greater sense of collective identity, family and community interdependence, and language barriers (Yamashiro & Matsuoka, 1997). Research also suggests that many Asian Americans rarely seek services until very late in their help-seeking process, when their conditions are extremely severe and other resources have been exhausted (Lin, T. Y., 1983; Lin, K. M., & Cheung, 1999).


Mistrust is another notable barrier to cultural competence in mental health. For example, fear of treatment and fear of being hospitalized are major reasons for underutilization of mental-health services among African Americans (Whaley, 2001). Another reason may be the bias, racism, and discrimination in the mental-health service system (Primm, Lima, & Rowe, 1996). A consistent theme that has emerged in research on the interracial context of mental-health counseling and services is that the mental-health environment is a microcosm of the larger society (Whaley, 1998), and White therapists and counselors are perceived by African American clients in a similar manner as Whites in other social contexts (Whaley, 2001). In other words, if an African American client displays a high level of mistrust of Whites in broader society, it is highly likely that the client will not trust a White clinician.

Research on the mental-health service utilization of Arab Americans is far less extensive, but existing studies suggest that clients of Arab origin hold a negative view of mental-health services and may mistrust and underuse them (Al-Krenawi & Graham, 2000). Although there are exceptions, based on educational attainment and degree of acculturation, most people of Arab origin perceive mental-health services in a negative light. According to Al-Krenawi and Graham (2000), Arab Americans do not distinguish among psychiatrists, psychologists, or other mental-health professionals, view them suspiciously as researchers or as doctors who eschew religious values, and fail to see them as a source of comfort and healing.

Clinical bias and misdiagnosis.

In addition to mistrust, clinical bias and inaccurate evaluation of the mental-health problems of racial and ethnic minorities are significant barriers to providing effective mental-health services and to service utilization. How the clinician perceives the client’s emotional state and behavioral symptoms relates to the diagnosis (Kirst-Ashman, 2013), and clinicians unfamiliar with the cultural beliefs and values of their clients may well misdiagnose or inaccurately evaluate the problem. For example, studies show that African Americans are diagnosed with schizophrenic disorders more frequently than are Hispanic/Latinos and Whites, and Hispanic/Latinos were disproportionately diagnosed as having major depression, although they reported significantly higher levels of psychotic symptoms (Minsky, Vega, Miskimen, Gara, & Escobar, 2003). Since the 1990s, researchers have consistently documented that African Americans have higher than expected rates of schizophrenia and lower rates of affective disorders, which aroused suspicion that mental-health professionals are biased in their practice and service delivery (Baker & Bell, 1999). Factors accounting for clinical misdiagnosis include differences in the availability of patient information, differences in the application of diagnostic criteria, the use of structured interviewing procedure versus unstructured interviewing procedure, and differences in interpretation of symptoms because of culture or language (Alegria et al., 2008). Most service providers also use clinical judgment of illness, trauma exposure, and history of abuse and victimization in the home. However, differential assessment for racial/ethnic minority clients can lead to increased likelihood of diagnostic bias (Alegria et al., 2008).

Directions for Enhancing Cultural Competence in Mental-Health Services

Despite a lack of research on whether cultural competence training leads to long-term changes in clinician behavior and better client outcomes (for example, Beach et al., 2005), frameworks, standards, and policies for enhancing cultural competence in mental-health services have emerged. These are generally based on professional ethical principles (such as the NASW code) or other best practices directed at reducing disparities and improving outcomes.

The Office of Minority Health of the USDHHS developed standards for culturally and linguistically appropriate services (Fortier, Taylor, Convissor, & Pacheco, 2001). These standards are focused at the organizational level. The 14 standards focus on delivering culturally competent care, staff diversity, the need for ongoing education and training, language-assistance services for those with limited English proficiency, and a strategic plan that address goals and accountability.

The Surgeon General’s report on mental health, culture, race, and ethnicity (USDHHS, 2001) concluded with six areas of recommendation including enhancing the scientific base, improving treatment access, and reducing barriers. The 2003 President’s New Freedom Commission on Mental Health Report (as cited by Druss & Goldman, 2003) states that culturally competent services are essential aspects of the mental health system and recommended that everyone should have access to quality care (Goal 3). The National Alliance on Mental Illness, an advocacy organization, recommends that Goal 3 be implemented as part of its advocacy agenda related to cultural competence in mental-health care. They also recommend the following reforms, among others (National Alliance on Mental Illness, 2012):

  • Put increased education, mandates, and enforcement measures in place so that all agencies that receive federal assistance fully understand and comply with their obligations to provide quality and equal treatment.

  • Make cultural competence education mandatory in clinical training programs and in continuing professional education in medicine, social work, and clinical psychology.

  • Ensure that government and private providers of mental-health services perform a cultural self-assessment, adopt cultural competence standards, embrace diversity, and adapt their services to address the needs of diverse populations.

Models for education and training often include information on assessment. Lim (2012) utilized the DSM-IV-TR outline for cultural formulation (American Psychiatric Association, 2000 as a basis for clinical training in cultural competence. The outline for cultural formulation covers five areas: cultural identity of the individual, cultural explanations of the individual’s illness, cultural factors related to psychosocial environment and levels of functioning, cultural elements of the relationship between the individual and the clinician, and overall cultural assessment for diagnosis and care (American Psychiatric Association, 2010). Lim (2012) also notes that other frameworks may be helpful; for example, the Hays (2008) “addressing” framework may help in assessing the individual’s cultural identity. This framework directs the clinician to attend to domains of difference according to the acronym “addressing”: age and generational influences, development and acquired disabilities, religion/spiritual orientation, ethnicity, socioeconomic status, sexual orientation, indigenous heritage, national origin, and gender.

Organizations concerned about behavioral health care are also advocating for cultural and linguistic competence. The Center for Integrated Health Solutions was funded by the Substance Abuse and Mental Health Services Administration and the Health Resources and Services Administration to promote the development of integrated primary- and behavioral-health services. The Center for Integrated Health Solutions “strives to promote culturally and linguistically competent service delivery systems to address growing diversity, persistent disparities, and health and behavioral health equity through design, implementation, and evaluation” (Center for Integrated Health Solutions, 2012).

Another organization formed with support from the Substance Abuse and Mental Health Services Administration and in partnership with the National Alliance of Multi-ethnic Behavioral Health Associations is the National Network to Eliminate Disparities. The purpose of the National Network to Eliminate Disparities is “to address disparities in behavioral health care” (National Network to Eliminate Disparities in Behavioral Health, 2012). The National Network to Eliminate Disparities “supports information sharing, training and technical assistance among organizations and communities dedicated to the behavioral health and well-being of diverse communities” (2012).

Social-work organizations have also developed resources that relate to behavioral health disparities and cultural competence. For example, the National Association of Deans and Directors of Schools of Social Work, with support from the USDHHS Office of Minority Health, conducted a curriculum infusion initiative on behavioral health disparities (Office of Minority Health and the National Association of Deans and Directors of Schools of Social Work, 2012). In addition, a review of research conducted by Office of Minority Health (2012) contains resources on eliminating disparities for racial and ethnic minority populations.


This entry discusses the problems of racial/ethnic disparities in mental-health services and challenges encountered by social-work professionals in providing mental-health services that are culturally responsive to racially/ethnically diverse clients. Although it is without doubt that significant progress has been made over the years in our understanding of cultural competency, serious work remains as social workers struggle to incorporate cultural competency in mental-health services for increasingly diverse populations.

Effective mental-health practice with people of color requires not only cultural competency but also cultural proficiency (Cross, Bazron, Dennis, & Isaacs, 1989). “Cultural proficiency” refers to expanding knowledge about cultural competence through research, development of new therapeutic approaches based on culture, and dissemination of the results of demonstration projects (Cross et al., 1989, p. 17). Despite a critical need for both, few agencies and organizations ever reach the level of cultural proficiency (Kirst-Ashman, 2013).

Nevertheless, the changing racial/ethnic demographics of the U.S. society underscore the importance of mental-health researchers, practitioners, and educators to equip themselves and their students with a broader knowledge of human potential and possibilities (Logan, 2003). Although acquiring cultural competency and cultural proficiency appear daunting, the end results will prove meaningful in advocating for effective mental-health services on behalf of diverse clientele.


Abe-Kim, J., Takeuchi, D. T., Hong, S., Zane, N., Sue, S., Spencer, M. S., et al. (2007). Use of mental health-related services among immigrant and Asian Americans: Results from the National Latino and Asian American Study. American Journal of Public Health, 97(1), 91–98.Find this resource:

Alegria, M., Nakash, O., Lapatin, S., Oddo, V., Gao, G., Lin, J., et al. (2008). How missing information in diagnosis can lead to disparities in the clinical encounter. Journal of Public Health Management and Practice, 14, S26–S35.Find this resource:

Al-Krenawi, A., & Graham, J. R. (2000). Culturally sensitive social work practice with Arab clients in mental health settings. Social Work, 25(1), 9–22.Find this resource:

Allen-Meares, P. (2007). Cultural competence: An ethical requirement. Journal of Ethnic & Cultural Diversity in Social Work, 16(3/4), 83–92.Find this resource:

American Psychiatric Association. (2000). Diagnostic and statistical manual text revision, 4th edition. (DSM-IV-TR). Washington, DC: APPI.Find this resource:

Anthony, W. A. (1993). Recovery from mental illness: The guiding vision of the mental health service system in the 1990s. Psychosocial Rehabilitation Journal, 16(4), 11–23.Find this resource:

Atdjian, S., & Vega, W. A. (2005). Disparities in mental health treatment in U.S. racial and ethnic minority groups: Implications for psychiatrists. Psychiatric Services, 56(12), 1600–1602.Find this resource:

Baker, F. M., & Bell, C. C. (1999). African Americans: Treatment concerns. Psychiatric Services, 50, 362–368.Find this resource:

Beach, M. D., Price, E. G., Gary, T. L., Robinson, K. A., Ggozu, A., Palacio, A., et al. (2005). Cultural competence: A systematic review of health care provider education interventions. Medical Care, 43(4), 356–373.Find this resource:

Betancourt, J. R., Green, A. R., Carrillo, J. E., & Ananeh-Firempong, O., II (2003). Defining cultural competence: A practical framework for addressing racial/ethnic disparities in health and health care. Public Health Reports, 118, 293–302.Find this resource:

Bhui, K., Warfa, N., Edonya, P., McKenzie, K., & Bhugra, D. (2007). Cultural competence in mental health care: A review of model evaluations. BMC Health Services Research, 7, 15.Find this resource:

Breslau, J., Aguilar-Gaxiola, S., Kendler, K. S., Su, M., Williams, D., & Kessler, R. C. (2006). Specifying race–ethnic differences in risk for psychiatric disorder in a USA national sample. Psychological Medicine, 36, 57–68.Find this resource:

Carson, N. J. (2011). The devil you know: Revealing racial/ethnic disparities in the treatment of adolescent depression. Journal of the American Academy of Child & Adolescent Psychiatry, 50(2), 106–107.Find this resource:

Center for Integrated Health Solutions (2012). Cultural competency. Substance Abuse and Mental Health Services Administration. Retrieved March 22, 2013, from

Cheung, F. K., & Snowden, L. R. (1990). Community mental health and ethnic minority populations. Community Mental Health Journal, 26, 277–291.Find this resource:

Coker, T., Elliott, M. N., Kataoka, S. H., Schwebel, D. C., Mrug, S., Grunbaum, J. A., et al. (2009). Racial/ethnic disparities in the mental health care utilization of fifth grade children. Academic Pediatrics, 9(2), 89–96.Find this resource:

Cross, T. L., Bazron, B. J., Dennis, K. W., & Isaacs, M. R. (1989). Toward a culturally competent system of care. Washington, DC: Child and Adolescent Service System Program Technical Assistance Center.Find this resource:

Cummings, J. R., & Druss, B. G. (2011). Racial/ethnic differences in mental health service use among adolescents with major depression. Journal of the American Academy of Child & Adolescent Psychiatry, 50(2), 106–107.Find this resource:

Dana, R. H. (1998). Understanding cultural identity in intervention and assessment. Thousand Oaks, CA: Sage Publications, Inc.Find this resource:

Davis, K. (1997). Managed care, mental illness and African Americans: A prospective analysis of managed care policy in the United States. Smith College Studies in Social Work, 67(3), 623–641.Find this resource:

DeNavas-Walt, C., Proctor, B. D., & Lee, C. H. (2005). Income, poverty, and health insurance coverage in the United States: 2004. U.S. Census Bureau, Current Population Reports, P60-229, Washington, DC: Government Printing Office.Find this resource:

Dobalian, A., & Rivers, P. A. (2007). Racial and ethnic disparities in the use of mental health services. The Journal of Behavioral Health Services & Research, 35(2), 128–141.Find this resource:

Druss, B. G., & Goldman, H. H. (2003). Introduction to the special section on the President’s New Freedom Commission Report. Psychiatric Services, 54(11), 1465–1466.Find this resource:

Dulmus, C. N., & Roberts, A. R. (2008). Mental illness: Adults. In T. Mizrahi & L. E. Davis (Eds.), Encyclopedia of social work (Vol. 3, pp. 237–242). Washington, DC: NASW Press.Find this resource:

Fabrega, H., Jr. (1991). Somatization in cultural and historical perspectives. In L. J. Kirmayer & J. M. Robbins (Eds.), Current concepts of somatization: Research and clinical perspectives (pp. 181–199). Washington, DC: American Psychiatric Press.Find this resource:

Fortier, J. P., Taylor, Y. S., Convissor, R., & Pacheco, G. (2001). Assuring cultural competence in health care: Recommendations for national standards and an outcomes-focused research agenda. Retrieved December 12, 2012, from

Freedman, A. M. (1967). Historical and political roots of the Community Mental Health Centers Act. American Journal of Orthopsychiatry, 37, 487–494.Find this resource:

Garland, A. F., Lau, A. S., Yeh, M., McCabe, K. M., Hough, R. L., & Landsverk, J. A. (2005). Racial and ethnic differences in utilization of mental health services among high-risk youths. American Journal of Psychiatry, 162, 1336–1343.Find this resource:

Gary, L. E. (1987). Attitudes of black adults toward community mental health services. Hospital and Community Psychiatry, 38, 1100–1105.Find this resource:

Green, J. W. (1982). Cultural awareness in human services. Englewood Cliffs, NJ: Prentice Hall.Find this resource:

Greeno, C. G. (2008). Mental health: Overview. In T. Mizrahi & L. E. Davis (Eds.), Encyclopedia of social work (Vol. 3, pp. 221–232). Washington, DC: NASW Press.Find this resource:

Grob, G. N. (1992). Mental health policy in America: Myths and realities. Health Affairs, 11, 7–22.Find this resource:

Hatzenbuehler, M. L., Keyes, K. M., Narrow, W. E., Grant, B. F., & Hasin, D. S. (2008). Racial/ethnic disparities in service utilization for individuals with co-occurring mental health and substance use disorders in the general population. Journal of Clinical Psychiatry, 69(7), 1112–1121.Find this resource:

Hays, P. (2008). Addressing cultural complexities in practice: Assessment, diagnosis, and therapy (2nd ed.). Washington, DC: American Psychological Association Press.Find this resource:

Helms, J. E. (Ed.). (1990). Black and white racial identity: Theory, research, and practice. New York, NY: Greenwood Press.Find this resource:

The Henry J. Kaiser Family Foundation. (2012). Community health centers: The challenge of growing to meet the need for primary care in medically underserved communities. Retrieved December 12, 2012, from

Institute for the Study of Health Care Organizations & Transactions. (2000). Mental health service research. Retrieved October 21, 2012, from

Kirst-Ashman, K. K. (Ed.). (2013). Introduction to social work & social welfare: Critical thinking perspectives. Belmont, CA: Brooks/Cole.Find this resource:

Korr, W. S., & Ford, B. C. (2003). Measuring quality of life in the mentally ill. Quality of Life Research, 12, 17–23.Find this resource:

Koyanagi, C., & Bazelon, D. L. (2007). Learning from history: Deinstitutionalization of people with mental illness as precursor to long-term care reform. Kaiser Commission on Medicaid and the Uninsured. Retrieved October 21, 2012, from

Larrison, C. R., Schoppelrey, S., Nowak, M. G., Brantley, J. F., Leonard, M., Crooke, D., et al. (2004). Evaluating treatment outcomes for African American and White clients receiving treatment at a community mental health agency in the rural south. Research on Social Work Practice, 14(3), 137–146.Find this resource:

Lasser, K. E., Himmelstein, D. U., Woolhandler, S. J., McCormick, D., & Bor, D. H. (2002). Do minorities in the United States receive fewer mental health services than Whites? International Journal of Health Services, 32(3), 567–578.Find this resource:

Leong, F. T. L., & Lau, A. S. L. (2001). Barriers to providing effective mental health services to Asian Americans. Mental Health Services Research, 3(4), 201–214.Find this resource:

Levin, J., Chatters, L. M., & Taylor, R. J. (2005). Religion, health and medicine in African Americans: Implications for physicians. Journal of the National Medical Association, 97(2), 237–249.Find this resource:

Lim, R. F. (2012). Cultural competence. In H. L. McQuiston et al. (Eds.), Handbook of Community Psychiatry. New York, NY: Springer Science + Business Media, LLC.Find this resource:

Lin, K. M., & Cheung, F. (1999). Mental health issues for Asian Americans. Psychiatric Services, 50(6), 774–779.Find this resource:

Lin, T. Y. (1983). Psychiatry and Chinese culture. Western Journal of Medicine, 139, 862–867.Find this resource:

Logan, S. M. L. (2003). Issues of multiculturalism: Multicultural practice, cultural diversity, and competency. In R. A. English (Ed.), Encyclopedia of social work, 2003 supplement (19th ed., pp. 95–106). Washington, DC: NASW Press.Find this resource:

McGuire, T. G., & Miranda, J. (2008). New evidence regarding racial and ethnic disparities in mental health: Policy implications. Health Affairs, 27(2), 393–403.Find this resource:

Mechanic, D. (1998). Emerging trends in mental health policy and practice. Health Affairs, 17(6), 82–98.Find this resource:

Minsky, S., Vega, W., Miskimen, T., Gara, M., & Escobar, J. (2003). Diagnostic patterns in Latino, African American, and European American psychiatric patients. Archives of General Psychiatry, 60(6), 637–644.Find this resource:

Morris, R. (1974). The place of social work in the human services. Social Work, 9(5), 519–531.Find this resource:

Mowbray, C. T., & Holter, M. C. (2002). Mental health and mental illness: Out of the closet? Social Service Review, 76(1), 135–179.Find this resource:

National Alliance on Mental Illness. (2012). Cultural competence in mental health care. Retrieved December 11, 2012, from

National Association of Social Workers. (2001). NASW standards for cultural competence in social work practice. Washington, DC: Author. Retrieved October 20, 2012, from this resource:

National Association of Social Workers. (2007). Indicators for the achievement of the NASW Standards for Cultural Competence in Social Work Practice. Washington, DC: National Association of Social Workers. Retrieved December 11, 2012, from this resource:

National Association of Social Workers. (2012). Mental health. Retrieved December 12, 2012, from

National Institute of Mental Health. (2007). African Americans, Black Caribbeans, and Whites differ in depression risk and treatment. Retrieved October 27, 2012, from

National Institute of Mental Health. (2010). Just over half of Americans diagnosed with major depression receive care. Retrieved October 27, 2012, from

National Institutes of Health. (1963). Public Law 88-164. Retrieved December 12, 2012, from

National Network to Eliminate Disparities in Behavioral Health. (2012). About NNED—Overview. Retrieved December 11, 2012, from

Neighbors, H. W., Caldwell, C., Williams, D. R., Nesse, R., Taylor, R. J., Bullard, K. K., et al. (2007). Race, ethnicity, and the use of services for mental disorders: Results from the National Survey of American Life. Archives of General Psychiatry, 64, 485–494.Find this resource:

Office of Minority Health and the National Association of Deans and Directors of Schools of Social Work. (2012). A behavioral health disparities curriculum infusion initiative: Eliminating behavioral health disparities for racial and ethnic minority populations: Workforce development to mobilize social work as a resource. Retrieved December 11, 2012, from

Oyserman, D., Kemmelmeier, M., Fryberg, S., Brosh, H., & Hart-Johnson, T. (2003). Racial–ethnic self-schemas. Social Psychology Quarterly, 66(4), 333–347.Find this resource:

Oyserman, D., & Lee, S. W. S. (2007). Priming “culture”: Culture as situated cognition. In S. Kitayama & D. Cohen (Eds.), Handbook of cultural psychology (pp. 255–279). New York, NY: Guilford Press.Find this resource:

Oyserman, D., & Sorensen, N. (2009). Understanding cultural syndrome effects on what and how we think: A situated cognition model. In R. S. Wyer, C. Y. Chiu, & Y. Y. Hong (Eds.), Understanding culture: Theory, research, and application (pp. 25–52). New York & London: Psychological Press, Taylor & Francis Group.Find this resource:

Padilla, Y. C. (1997). Immigrant policy: Issues for social work practice. Social Work, 42(6), 595–606.Find this resource:

Primm, A. B., Lima, B. R., & Rowe, C. L. (1996). Cultural and ethnic sensitivity. In W. R. Breakey (Ed.), Integrated mental health services: Modern community psychiatry (pp. 146–159). New York, NY: Oxford University Press.Find this resource:

Ridley, C. R., Baker, D. M., & Hill, C. L. (2001). Critical issues concerning cultural competence. The Counseling Psychologist, 29, 822–832.Find this resource:

Samaan, R. A. (1998). The influences of race, ethnicity, and poverty on the mental health of children. Journal of Health Care for the Poor and Underserved, 11(1), 100–110.Find this resource:

Segal, A. (1970). Workers’ perceptions of mentally disabled clients: Effect on service delivery. Social Work, 15(3), 39–46.Find this resource:

Smedley, B. D., Stith, A.Y., & Nelson, A. R. (2002). Unequal treatment: What health care providers need to know about racial and ethnic disparities in healthcare. Washington, DC: National Academy Press.Find this resource:

Sue, S. (2006). Cultural competency: From philosophy to research and practice. Journal of Community Psychology, 34(2), 237–245.Find this resource:

Taylor, R. J., Ellison, C. G., Chatters, L. M., Levin, J. S., & Lincoln, K. D. (2000). Mental health services in faith communities: The role of clergy in Black churches. Social Work, 45(1), 73–87.Find this resource:

Thomas, A. R. (1998). Ronald Reagan and the commitment of the mentally ill: Capital, interest groups, and the eclipse of social policy. Electronic Journal of Sociology. Retrieved October 21, 2012, from

Thomas, A., & Sillen, S. (1972). Racism and psychiatry. New York, NY: Brunner/Mazel.Find this resource:

Towery, O. B., & Windle, C. (1978). Quality assurance for community mental health centers: Impact of P.L. 94–63. Psychiatric Services, 29(5), 316–319.Find this resource:

Trattner, W. I. (1994). From poor law to welfare state: A history of social welfare in America (6th ed.). New York, NY: Free Press.Find this resource:

Turner, J. C., & TenHoor, W. M. (1978). The NIMH Community Support Program: Pilot approach to social reform. Schizophrenia Bulletin, 4, 319–349.Find this resource:

U.S. Census Bureau. (2010). 2010 Census shows America’s diversity. Retrieved October 20, 2012, from

U.S. Department of Health and Human Services. (1983). Health, United States (PHS 84-1232). Hyattsville, MD: National Center for Health Statistics.Find this resource:

U.S. Department of Health and Human Services. (2001). Mental health: Culture, race, and ethnicity—A supplement to mental health. A report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Series, Public Health Service, Office of the Surgeon General.Find this resource:

van Olphen, J., Schulz, A., Israel, B., Chatters, L., Klem, L., Parker, E., et al. (2003). Religious involvement, social support, and health among African-American women on the east side of Detroit. Journal of General Internal Medicine, 18(7), 549–557.Find this resource:

Weaver, H. (1999). Indigenous people and the social work profession: Defining culturally competent services. Social Work, 44(3), 217–225.Find this resource:

Wendt, D. C., & Gone, J. P. (2012). Rethinking cultural competence: Insights from indigenous community treatment setting. Transcultural Psychiatry, 49(2), 206–222.Find this resource:

Whaley, A. L. (1998). Racism in the provision of mental health services: A social-cognitive analysis. American Journal of Orthopsychiatry, 68, 47–57.Find this resource:

Whaley, A. L. (2001). Cultural mistrust and mental health services for African Americans: A review and meta-analysis. The Counseling Psychologist, 29(4), 513–531.Find this resource:

Whaley, A. L., & Davis, K. E. (2007). Cultural competence and evidence-based practice in mental health services. American Psychologist, 62(6), 563–574.Find this resource:

Williams, D. R., Gonzalez, H. M., Neighbors, H., Nesse, R., Abelson, J. M., Sweetman, J., & Jackson, J. S. (2007). Prevalence and distribution of major depressive disorder in African Americans, Caribbean Blacks, and non-Hispanic Whites: Results from the National Survey of American Life. Archives of General Psychiatry, 64(3), 305–315.Find this resource:

Yamashiro, G., & Matsuoka, J. K. (1997). Help-seeking among Asian and Pacific Americans: A multiperspective analysis. Social Work, 42(2), 176–186.Find this resource: