Addressing Cultural and Racial Disparities in Behavioral Healthcare

All behavior is learned and displayed within the contexts of society. Each individual’s culture is a unique blend of ethnicity, demographics, socioeconomic status, language, and affiliations. If practitioners assess and evaluate behavior through a client’s frame of reference, human behavior becomes more evident in light of its cultural context.

Unfortunately, there are healthcare disparities among diverse populations, and behavioral health is no exception. For example, treatment retention rates are significantly lower for African Americans and Latinos when compared to the white population. As the behavioral healthcare industry incorporates new technologies, there are additional opportunities to address minority health disparities. The wide-spread use of Electronic Health Records (EHRs) offers large-scale demographic data that can reveal underlying social discrepancies. With better data, clinicians can individualize treatment interventions with culturally-relevant practices. 

Racial and Ethnic Groups

Race is a social construct that groups people based on shared physical characteristics. The perception of race has a profound impact in terms of mental health, opportunities, and societal status. Ethnicity is distinct from race. It stems from social identity and a mutual sense of belonging, rather than physical characteristics. For example, Hispanics may self-identify in terms of their ethnicity (Cuban, Mexican, Colombian) and their race (black, white, American Indian).

Factors such as discrimination, assimilation, ethnic pride, and culture affect an individual’s mental and behavioral health, so it’s important that clinicians tailor treatments to meet the specific ethnic and racial needs of their clients. For example, social stigma often prevents Asian Americans from seeking services, so an essential step in providing treatment for Asian Americans is assessing their experience with shame and guilt.

African Americans tend to experience more barriers to treatment for mental health issues. Many may lack insurance, childcare, or knowledge of available services. Several studies reveal that African Americans are over-diagnosed for some disorders, such as substance use disorder (SUD), while under-diagnosed for others, such as anxiety and mood disorders. Clinicians need to consider these factors when they diagnose and treat their African American clients.

Tradition, Religion, and Culture

Cultural identity is dynamic and multi-faceted. For some, socioeconomic status, geographic location, language, or religion play a more significant role than race or ethnicity in defining their culture. A child adopted from China now living in the United States may identify more with American culture than Asian culture. A poor white person may have more in common with a poor black person, than they do a wealthy person of their own race. Awareness of a patient’s cultural traditions can provide a framework for clinicians.

For some clients, integrating their cultural and religious practices into evidence-based treatment can improve outcomes. Desert Visions, a substance use center in Arizona, serves American Indian youth. Their interventions combine tribal, cultural and spiritual practices with evidence-based Dialectical Behavior Therapy (DBT). The DBT approach, which teaches emotional regulation through mindfulness, is a modified form of Cognitive Behavior Therapy. A three-year statistical review showed that 96% of Desert Visions’ clients showed clinically significant improvement in substance use disorder, while none deteriorated, using this evidence-based plan.

Lesbian, Gay, Bisexual, and Transgender 

Lesbian, gay, bisexual, and transgender (LGBT) individuals often face health disparities due to social stigma and prejudice. Harassment, family rejection, and denial of rights is still prevalent among these populations. Discrimination against LGBT people is linked to higher rates of mental illness, SUD, and suicide. In a nationwide survey, 43% of homosexual and bisexual high school students reported seriously considering or attempting suicide, compared to 15% of their heterosexual counterparts. 

In some ways, LGBT populations are an “invisible” minority. Many do not disclose their orientation or gender identity to healthcare providers. Collecting intake data on sexual orientation and gender identities provides clients an opportunity to share information that may go unnoticed. EHRs can improve quality of care by tracking outcomes and revealing health disparities among LGBT populations. 

Criminal Justice Populations

Prisons have replaced hospitals as the primary facilities for mentally ill populations. There are 10 times more people with serious mental illness in state prisons than in state hospitals. The “war on drugs” and a lack of community-based services have drastically increased the incarceration rates of people with behavioral health conditions. Approximately half of inmates in jails and prisons meet the criteria for mental illness, and 15-20% of those with mental illness in that population are diagnosed with serious psychiatric conditions.

Insufficient pre-release counseling and post-release follow-up mean mentally ill inmates leave prison in the same or worse condition as when they entered. Many with SUD return to substance misuse with a lower tolerance, raising the risk of overdose deaths following release. Some states are working to combat this problem with Drug Courts. These specialized programs provide treatment services in place of jail time, and are associated with a significant reduction in repeat offenses.

Veterans and Military Service Members

Military members, veterans, and their families require special considerations. Military culture values service above self, and the stigma around mental health treatment can be a barrier. Service members worry that seeking treatment will negatively impact their career. Military and veteran populations have higher rates of SUD, Posttraumatic Stress Disorder (PTSD), depression, and traumatic brain injury than what is seen in the general population. For many, SUD and PTSD are linked. Decreases in substance misuse correlate with improvements in PTSD. Specialized intensive treatment and proper discharge planning may result in better outcomes for veterans. 

Using Technology to Address Disparities

Health information technology is a useful tool that can be used to address cultural and racial disparities. The collection of race, ethnicity, orientation, and language data is an important opportunity for providers to lessen discrepancies in treatment. Systematic data collection with an EHR gives clinicians the information they need to ask the right questions. Aggregated data provides keen insight into health disparities which, in turn, allows providers to better meet their clients’ needs. Teletherapy is a promising technology for improving access to resources and services for underserved populations. Teletherapy is well-suited for behavioral healthcare applications, with the goal of expanding access to care for minorities and subgroups who may otherwise go untreated.

Race, ethnicity, orientation, gender, and background all play a role in a person’s mental health. Many clinicians may wonder how they can address cultural and racial disparities in their own practice. Addressing disparities starts with providers becoming comfortable with cultural differences while remaining aware of their own worldview. Culturally aware therapists should consider the psychological effects of culture and society on diverse populations and develop intervention goals that align with the client’s values. Take the time to get to know your client’s perspective, because in the end, behavioral healthcare is about improving patient outcomes and helping others. 

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