As a significant first step towards eliminating disparities through culturally competent practices responsive to California’s cultural communities, the California Institute for Mental Health (CiMH), through the Center for Multicultural Development (CMD), conducted the Seven County Study with funding from The California Endowment. This study was designed to document strategies implemented by California’s mental health system in promoting cultural competence. Our aim was to identify and evaluate the breadth and effectiveness of specific cultural competence activities in seven counties in order to advance policy and help operationalize culturally competent practices. The Seven County Study yielded significant information towards understanding the implementation of cultural competence activities in working with cultural, ethnic, racial and linguistic communities throughout California.

Four specific main themes emerged from our analysis of the culturally competent strategies implemented within these seven counties:

1. The conceptualization of cultural competence (policy, organizational and clinical levels);
2. Best practices including ethnic-specific clinics, outreach programs and training;
3. Key challenges or barriers to addressing cultural competence;
4. Strategies to overcome such barriers in order to further culturally competent practices with consumers and diverse community stakeholders.

Conceptualizing Cultural Competence

To help organize our findings on cultural competence activities carried out in the seven counties, we used a conceptual framework classifying these activities based on whether they were carried out at policy, organizational or clinical levels. Although the focus of the Seven County Study was clinical level practices, it became clear through the interviews and site visits that counties placed greater emphasis on identifying practices at the organizational and policy levels. We found that in practice, cultural competence is characterized as a set of values communicated through policies. Having to adhere to policies, organizations are made aware of these values of cultural competence—values that organizations are often mandated to put into practice on a clinical level.

Despite this emphasis on the policy level, informal policies and procedures surrounding cultural competence were more frequently referenced than written, formal policies and procedures. The sheer energy and commitment of staff drove many of the programs developed to serve diverse populations. For example, in site visits, customer service was observed to be positive, respectful and friendly; many practice sites were co-located with other programs providing consumers with more service options under one roof; staff were flexible, mobile, bilingual and bicultural; and written materials for consumers were available in multiple languages.

It is at the clinical level that culturally competent practices and their range of potential activities fall short of being realized. With the seven counties, there was ambiguity around what cultural competence looks like at the clinical level. Respondents who were interviewed, as well as documents that made reference to cultural competence, were unable to describe or explain in specific terms how cultural competence is worked into clinical practice. However, interview data revealed general, clinical activities based on cultural competence standards in the literature. General clinical activities primarily involved outreach and engagement whereby clinicians, in their everyday work, reach out to diverse consumers of mental health services and engage them in a way that considers cultural norms, values, and treatment expectations.

For example, Feather River Tribal Health Center in Butte County incorporates cultural knowledge in working with American Indians. Understanding the “two worlds in which American Indians walk,” an administrator at the Center shared in an interview that many tribal communities face a “white society that promotes individuality” and at the same time a “tribal society that joins as a family where everything is done as a collective prayer.” Also in Butte County is the Annual Hmong Outings program where Hmong consumers are taken on hiking, camping or fishing trips for outreach and therapeutic purposes. The number of Hmong clients who have been assessed or received mental health services has increased tremendously since the outings began. Clients who partake in the outings take the message back to their community that involvement with the county’s mental health department is not the frightening and/or humiliating process that it is often perceived to be.

The cultural knowledge to engage consumers is also evident in Alameda County’s Asian Community Mental Health Center. A provider at the center noted that speaking the language of the consumers is just one basic need. Successful outreach, engagement and retention of consumers in the Asian community is contingent upon many factors, including compassion, sense of dignity, confidentiality (e.g., avoiding public signs in front of the center) and understanding that mental illness is considered shameful to many Asians and Asian Americans. As a consumer at this center noted, "The stigma is a real barrier."

Best Practices

Extensive, in-depth interviews were conducted and analyzed, yielding 152 indicators of cultural competence. In order to prioritize the multiple indicators of cultural competence and identify best practices, the indicators were categorized into 18 clusters of activities that most likely promote culturally competent practice. These 18 best practices represent the most prominent themes of cultural competence across the seven counties.

To further guide our data analysis, we utilized a conceptual framework for cultural competence presented by the Lewin Group in a report prepared for the Health Resources and Services Administration of the U.S. Dept. of Health and Human Services in 2002. We used the seven components or domains of cultural competence identified by the Lewin Group, and specific focus areas for each domain, to help analyze and organize the evidence gathered by the Seven County Study. The 18 best practices identified in the study corresponded to three of the Lewin Group domains and six of the focus areas. The best practices were organized according to these domains and focus areas and presented with examples from the seven counties in the following table:

Table I: Cultural Competence Best Practices from the Seven County Study.

Several specific community-based clinics with services tailored to meet the needs of cultural communities were also identified and described. These clinics and county agencies within the seven counties carry out discrete practices and programs that can be considered emerging practices or practices with practice-based evidence of effectiveness. These practices and programs were identified and are listed as follows:

1. Proyecto Radionovelas
2. Hmong Outings
3. Native American Liaison
4. Los Niños Bien Educados
5. Cena Con Sus Hijos
6. Multicultural Assessment Intervention Process Model

Barriers to Cultural Competence

There were three primary factors that the seven counties identified as barriers to executing culturally competent practices. The first factor related to the lack of formalized policies and procedures around cultural competence. The interview data, document reviews and site visits revealed the absence of concrete guidelines for counties to follow in the development, implementation and evaluation of culturally competent practice, as well as the dissemination of critical information to put the principles of cultural competence into practice. The omission of such guidelines was particularly evident in the lack of defined roles for staff, including ethnic services managers, quality improvement and assurance staff and data and technical assistance staff. Otherwise stated, the role of county mental health directors as leaders of this effort was apparent; however, no other roles for building an infrastructure to embed cultural competence into the mental health system were explicitly defined.

The second factor or barrier to cultural competence practice was the lack of involvement of diverse stakeholders in the process of developing and evaluating programs. The interviews with administrative staff from county mental health departments especially revealed the absence of a concerted effort to involve diverse stakeholders in developing and evaluating programs that target diverse ethnic populations. As a consequence, there was no consensus on what types of information about diverse populations are important to help sustain programs that may be effective for a particular ethnic group of mental health consumers.

The third factor was the lack of systematic data collection on diverse consumers of mental health services. The Cultural Competence Plans and related documents provided by the seven counties showed little-to-no infrastructure for systematic data collection, nor was there a structure in place within departments to utilize data for developing culturally competent practices. Based on the research teams’ document reviews, there was no consistency in collecting data, reporting data and disseminating data within organizations, across communities and among policymakers. As one provider noted, “We don’t get information back unless it is grant writing time [or] time for grant documentation.” Though it is not uncommon for service delivery systems to lack a comprehensive system for collecting information, its absence with respect to diverse populations could be an indication that the need for relevant data across counties has not been fully recognized.

Overcoming Barriers

Overall, the seven representative counties executed a number of strategies for overcoming barriers and infusing cultural competence into their practice. The counties overcame barriers by developing and implementing key strategies at the clinical, organizational and policy levels.

On a clinical level, culturally competent practice was primarily seen in the integration of cultural knowledge into screening, assessment, planning and treatment. Despite the lack of explicit formal policies and procedures to institutionalize culturally competent practice, most of the seven counties had several services or programs that unequivocally applied cultural knowledge into their clinical practice.

Additionally, the counties’ investments in staff development exemplified key strategies for cultural competence on an organizational level. Though the counties expressed the need for more resources, plans were in place to allocate resources to cultural competence training, bilingual staff, and interpreters. In most counties, these plans were already being implemented.

Finally, on a policy level, the seven counties showed considerable effort in bridging the communication gap between mental health systems and diverse consumers of mental health services. Few policies and procedures explicitly called for involving consumers, their families and communities in planning, implementing and evaluating culturally competent practices, yet most counties made strong attempts to get input from consumers by addressing obstacles to communication. Counties used bilingual and bicultural staff, cultural brokers, interpreters and outreach and engagement strategies to foster participation from diverse populations in shaping culturally competent practice in mental health.

Next Steps

Having completed the Seven County Study, the CMD has now taken a two-pronged approach in seeking to promote practices effective in working with ethnic, racial and linguistically diverse communities to help eliminate disparities in care. The first has been to identify practices with an existing body of research evidence indicating their effectiveness at addressing disparities. The second prong to our approach is to support the development of a research base for community-based practices so that practices that are considered effective in communities will get supported and replicated.

Further work that could be carried out to build upon the findings of the Seven County Study would be to promote, formulate and evaluate promising practices to build their levels of evidence so they can be more widely disseminated. This would involve manualizing and researching the discrete practices listed above, as well as formulating new practices based on the practices listed in Table I: Cultural Competence Best Practices from the Seven County Study and manualizing and evaluating these new practices.