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As a nation, the United States continues to grow in diversity; our face, voice, and beliefs are forever changing. Not only are we changing as a Nation, so too is the way health care is being provided, in large part due to the ongoing managed care revolution. Despite the pace at which change in the healthcare marketplace is occurring, in many ways, the Nation’s health delivery systems have not kept pace with our growing diversity. A significant disconnect has arisen between health care need and the availability and accessibility of relevant, culturally competent care for people who need it. Perhaps nowhere is the importance of culturally competent care greater than in the delivery of mental health services, where cultural issues and communication between consumer and provider are a critical part of the services themselves.
Cultural Competence Standards in Managed Care Mental Health Services: Four Underserved/Underrepresented Racial/Ethnic Groups is designed to provide readers with the tools and knowledge to help guide the provision of culturally competent mental health services within today’s managed care environment. This document melds the best thinking of expert panels of consumers, mental health service providers, and academic clinicians from across the four core racial/ethnic populations: Hispanics, American Indians/Alaska Natives, African Americans, and Asian/Pacific Islanders. Developed for consumers, mental health service providers, educators, and organizations providing managed behavioral health care, the document provides state-of-the-science cultural competence principles and standards— building blocks to create, implement and maintain culturally competent mental health service networks for our diverse population.
This volume is divided into five sections. This introductory section sets a context, providing a demographic and health profile of people of African Descent, Asian and Pacific Islanders, Latinos and American Indian, Native Alaskan and Native Hawaiians. The balance of the text guides the perspectives of these four ethnic/ racial groups, moving from the articulation of 16 guiding principles that should underlie the establishment of cultural competence in a managed care environment (Section I—Guiding Principles) to specific system and clinical standards and implementation strategies. By focusing on principles—such as culturally competent approaches to integrated services, consumer empowerment, and appropriate outcomes— health care providers and provider organizations can help ensure success in reaching and responding to the needs of underserved racial and ethnic populations.
Sections II and III present overall system and clinical standards and implementation guidelines, placing a clear emphasis not only on cultural competence, but also on the contribution of cultural competence to quality of care. The standards also reflect generally accepted principles for the best way to provide clinical care for persons with mental illnesses. They also describe expected levels of culturally competent system and clinical behavior as well as courses of action necessary to achieve culturally competent care. These consensus-built standards also serve as a yardstick against which to measure managed care systems’ cultural proficiency in meeting the mental health care needs of the target populations.
The volume concludes with a review of the necessary and highly critical provider competencies, the application of knowledge and the interpersonal decision making and psychosocial skills expected for the practice role (Section IV), and a glossary of terms.
America’s population is growing and changing dramatically. Present and projected changes in America’s ethnic composition challenge the capabilities of mental health systems. The U. S. population has always been multi-ethnic and its composition in flux (Bogue, 1985; Sutherland, 1966). However, popular awareness of different cultural groups has increased in the last few decades. Shifts in ethnic diversity are not just about numbers, but are also about the impact of cultural differences. It is important to note that culture is not simply determined by ethnicity and a particular set of beliefs, norms, and values. Culture also involves the historical circumstances leading to a group’s economic, social, and political status in the social structure. Culture involves the circumstances and experiences associated with developing certain beliefs, norms, and values (Charon, 1995; APA, 1996). More specifically, this is especially true about the socioeconomic and political factors which have a significant impact on a group’s or its members’ psychological well-being (Muñoz & Sanchez, 1997).
In relation to mental health systems, new approaches are needed in service delivery to address cultural differences among consumers. The essential point for mental health providers is that people develop different approaches in response to their life circumstances. Mental health providers are beginning to realize that cultural competence in diversity is an important component in providing effective mental health services. Therefore, it is important that mental health providers are aware of the underlying pattern and history of America’s diversity (Muñoz & Sanchez 1997).
| Total Population by Race/Ethnicity (in millions/percentage of total population) |
||
| Populations | 1996 | 2050 |
| Hispanics | 27.8 (10.5%) | 96.5 (24.5%) |
| African American | 32.0 (12.1%) | 53.6 (13.6%) |
| Asian and Pacific Islander | 9.1 (3.4%) | 32.4 (8.2%) |
| American Indian, Eskimo, Aleut | 2.0 (.07%) | 3.5 (0.9%) |
| White | 194.4 (73.3%) | 207.9 (52.8%) |
| Total | 265.4 (100%) | 393.9 (100%) |
| Source: Source: U.S. Bureau of the Census, 1996. Hispanic can be of any race; data for all other groups are non-Hispanic. | ||
The term “Latino(s),” as used in this publication, refers to all persons of Mexican, Puerto Rican, Cuban, or other Central and South American or Spanish origin. Latinos comprise significant populations in virtually all the United States, now numbering more than 27,800,000 people, or 10.5% of the national population, a 50% increase over 1980. It is projected to grow to 29 million by the year 2000 and 96.5 million by the year 2050. At that time, Latinos will clearly be the largest ethnic group in the United States. Latinos, or Hispanics, are widely recognized as being a major part of the fabric of the Southwestern United States, such as California, Texas, New Mexico, and Arizona. However, they can also be found in significant numbers and percentages in such diverse states as Florida, Colorado, Nevada, New Jersey, Illinois, Utah, and Washington State. Latinos also have a significant presence in 25 metropolitan areas of the country.
The Latino population in the United States is not homogenous, but is composed of an extremely diverse group of nationalities of origin. These include 13.4 million of Mexican origin, 2.4 million of Puerto Rican heritage, Cuban, 1.1 million, and 2.9 million from Central and South American countries. Their cultural backgrounds are diverse, including Spanish, Aztec, Mayan, Incan, and Caribbean cultures, and Native American, White, and African American racial/ethnic origins. Despite their common language and link with Spanish culture, Latinos’ diverse religious, folk, family, and health beliefs and values as well as diverse linguistic idioms make them one of the most culturally rich groups in America.
Latinos have been adversely affected by under-education, under-employment, inadequate housing, and insufficient access to health care insurance. They also have disproportionately low rates of outpatient mental health service utilization and rates of admission for care. Latinos often perceive historic U.S. mental health models as unnecessary, unwelcoming, or not useful. A national conference held in Denver, Colorado in May 1995, attended by more than 100 Latino mental health professionals, concluded that Latinos, while affected by numerous socioeconomic stressors, remain likely to use mental health services primarily in crisis circumstances, drop out of services sooner, and have undesirable treatment outcomes. From that conference, a national panel was created to begin developing a set of national standards for delivering mental health services for Latino populations in a managed care setting. When the panel began its work in January 1996, several concepts were self-evident. Latinos have disproportionately less access to the full range of mental health services normally expected within any given state. They do not have comparable rates of use of ongoing outpatient services, have lower rates of voluntary hospitalization, and use crisis and other higher-cost services at higher rates than other populations.
Mental health staff who have trained in general practice often do not consider cultural competence as necessary or even valid. Thus, there is a tendency not to incorporate cultural competence principles in service development and planning models at the local and state level, nor to use those principles in direct service delivery. These factors are particularly important when comparing briefly a feefor- service to a managed care service model. In a fee-for-service environment, any service provided to a client results in a revenue to the organization which provided the unit of service. In a managed care or capitated rate environment, delivery of a service to an individual becomes a cost; and the fewer the services delivered in a set rate environment, the higher the profits. If Latinos have low utilization rates of mental health services in a fee-for-service environment where there are incentives to the provider to deliver the service, it follows that Latinos are more at risk in a managed care environment. In the managed care context, service delivery becomes a cost to an organization which is paid a flat rate per person served, irrespective of what the total price of service might be.
In a private insurance setting, the fee-for-service versus managed care example is particularly true, in that there is the ability to limit costs by limiting services. When the total number of sessions or hospitalization days allowed by an insurance company is exhausted, the remaining costs become the responsibility or burden of the insured. In a public setting, governmental sponsors expect that provider organizations will deliver certain outcomes within a fixed or capitated rate and be financially at risk for costs above that. Thus it becomes critical that costs be managed by delivering services effectively rather than by limiting benefits. In this environment, it is important to understand access and utilization patterns, outcomes, outliers, and cost by groups and by types of service. Service groups’ and subgroups’ needs must be known to meet them effectively and attain desirable outcomes within a fixed cost.
The Latino national panel made several other assumptions:
The terms African American and Black are used interchangeably here to refer to people of African descent. Some scholars trace the history of African people in North America to 1619 (Bennett, 1966), while others propose that African people entered the Americas several centuries before that date (Van Sertima, 1976). During the period from 1619 to 1997, the proportion of people of African descent in North America has ranged between 10-19% (U.S. Department of Commerce, 1995) of the total population of the United States. In 1790, Blacks constituted their largest proportion (19%) of the total U.S. population, and their smallest proportion (9.7%) was recorded in 1930 (U.S. Department of Commerce, 1995). The Black population of the United States is growing at about 1.3% per year, one of the slowest growth rates of all populations in the country. In 1997, people of African descent numbered close to 33 million or 12.6% of the U.S. population. The majority (52.8%) of the Black population in the U.S. resides in the south (U.S. Department of Commerce, 1995), although this figure is considerably lower than in previous decades. The smallest proportion (9.4%) of people of African descent reside in the west.
Between 1619 and 1860, the majority of the people of African descent came to the United States from the western coast of Africa as part of the flourishing slave trade. Since 1860, growth in the population of people of African descent in the U.S. has come about primarily through births, which have continued to exceed the national family average. Although immigration of people of African descent into the country has increased over past decades, Black African immigrants remain the smallest number of all immigrants to the United States (U.S. Department of Commerce, 1995). Immigration of Black people in the past decade from Egypt, Ethiopia, Ghana, Nigeria, Haiti, Panama, Jamaica, Trinidad, Barbados, and other Caribbean nations has significantly increased the nationalistic, cultural, religious, and language diversity within the Black population in the United States (U.S. Department of Commerce, 1995).
Historical and current data about the health status of American populations confirm that there are significant differences in prevalence and incidence of physical and mental health problems among groups based on culture, color, income, and country of origin. Also noted are major differences in help-seeking patterns (Neighbors, 1986). In two special reports (Center for Health Economics Research, 1993; Robert Wood Johnson, 1991), it was noted that people of color, particularly residents of inner cities, showed major disparities in their health status when compared to other populations. The disparities cover the range of disorders from high neonatal mortality rates per live birth, higher rates of heart and circulatory problems, disproportionate rates of AIDS and related deaths, greater prevalence of chronic conditions, higher rates of toothlessness, and higher rates of admissions to psychiatric facilities (Center for Health Economics Research, 1993; Robert Wood Johnson, 1991). The high incidence of substance abuse, physical injuries, and deaths from violence characterize low income Black neighborhoods and communities in terms of potential and actual costs of health care. According to some reports, substance abuse is the most significant health problem in the nation (Institute for Health Policy, 1993). These populations also show lower availability of health insurance and a significantly lower proportion of health professionals within easy access of their neighborhoods.
From the time that state governments decided to provide and finance residential care for the long-term mentally ill, major public policy paradoxes have been raised and debated about race and mental illness (Jarvis, 1844). The first of these paradoxes centers on the incidence and prevalence of severe mental illness in populations of African descent, while the second centers on the extent to which these populations require and consume public and/or proprietary mental health services (Snowden & Cheung, 1990). A cursory review of the data on admissions to inpatient psychiatric facilities (Manderscheid & Sonnenschein, 1987; Scheffler & Miller, 1989; Snowden & Cheung, 1990) shows disproportionately high rates of admissions by African Americans to all types of inpatient facilities. These data (Manderscheid & Sonnenschein, 1987; Snowden & Cheung, 1990; Snowden & Holschuh, 1992) show that, between 1980 and 1992, the rate of admission for all persons to state hospitals in the United States was approximately 163.6 per 100,000. The rate for Whites was 136, while the rate for Hispanics was 146 and the rate for Native Americans and Asians was 142 per 100,000 (Manderscheid & Sonnenschein, 1987). The admission rate to state hospitals for those of African descent for that same year was 364.2 per 100,000 population.
Admissions to general hospitals with psychiatric units showed similar patterns by race and ethnicity. For the population as a whole, the rate per 100,000 was 295.3 per 100,000, while the rate for the White population was 284.9. The rate during the same period for those of African descent admitted to general hospital psychiatric units was 386.6 per 100,000. While the national mean admission rate to Veterans Administration hospitals was 70.4 per 100,000, populations of African descent had a rate of 118.2 per 100,000. No other racial or ethnic population had an admission rate to the Veterans’ Administration hospitals that approximated the rate for populations of African descent.
When age is examined, the relationship between admissions to psychiatric hospitals and race is more pronounced. For example, the rate of admissions to state psychiatric hospitals for those of African descent between the ages of 25-44 was 598 per 100,000, while the national mean was 163.6 (Manderscheid & Sonnenschein, 1987). The most excessive rate found was for those of African descent between the ages of 25-44 where 753 per 100,000 were admitted to state psychiatric hospitals (Manderscheid & Sonnenschein, 1987). Although admissions are not indicative of actual prevalence rates in the population, these data show clearly an inveterate pattern of service utilization differentiated by race and class. Data from the National Institute of Mental Health (Manderscheid & Sonnenschein, 1987) show that Blacks were more frequently diagnosed on admission with severe mental illness than other ethnic or racial populations. According to data on admissions of Blacks to state mental hospitals, 56% of these individuals received a primary diagnosis of schizophrenia, while only 38% of all individuals received a similar diagnosis. Garretson (1993), Flaskerud and Hu (1992), Jones and Gray (1986), and Lawson and colleagues (1994) conclude that the primary reasons for the disproportionate rate of severe mental illness diagnoses are errors made by diagnosticians who are unfamiliar with mental illness as it is manifested in populations of color.
Decades of knowledge in the literature about how populations of African descent consume mental health services show that people of African descent:
These data reflect a number of conclusions that may be helpful as the nation sets its course towards managed behavioral health care in the public and private sectors. It is clear that under the prior and present systems of care, individuals of African descent with serious mental illness were and are not served well. Diagnoses were found to have been in error, inpatient admission rates were disproportionately high, involuntary admissions were used with great frequency; and the most severe mental illness labels were ascribed at a rate that appears higher than its expected frequency in the population. Of significance as well are the findings of different patterns of help seeking and help utilization on the part of African American populations. Populations of African descent tend to delay seeking help for psychiatric problems (as well as major health problems) from formal health systems until conditions have become more serious or chronic and most other community and familial resources have been exhausted. Those of African descent also do not continue to use outpatient services or as many service units as other populations, although their diagnoses are more severe. Each of these conclusions implies important clinical and marketing issues for managed behavioral health care processes and values. As new managed care policies and services are being developed to reduce unnecessary services and excessive costs, more attention should be given to the poorly understood service issues and dilemmas related to race and severe mental illness.
With the implementation of managed care policies, the paradoxes associated with race and mental illness are likely to impact disproportionately on low income communities of color. For managed care to serve consumers of African descent with severe mental illness effectively, significant focus must be on issues of access, as well as accuracy of diagnosis and quality of treatment. Too often clinical issues are not examined from an ethnic or racial perspective because they do not fit the dominant cultural perspective. Even those professionals who have been educated in urban areas with large concentrations of minority populations may be conditioned to assess consumers using standards and guidelines that are not culturally specific or sensitive. In a behavioral health care environment that seeks to penetrate the market of consumers who are of African descent, there is a need to establish standards and guidelines for managed care systems, organizations, and providers.
The terms Asian, Asian Americans, or Asian/Pacific Islander will be used when referring to this group, which is the most diverse in terms of ethnic origin, cultural background, immigration history, and acculturation to U.S. culture. For example, Asian Americans comprise at least 31 ethnic groups. Yet, Asian and Pacific Islanders are often misunderstood to be a homogeneous ethnic group. Unfortunately, failure to make distinctions among the diverse ethnic, cultural, and language groups comprising Asian and Pacific Islanders, and tendencies to generalize their economic, social, and political circumstances, can lead to faulty conclusions about individuals’ mental health needs.
In terms of percentage increase, Asian Americans are the fastest growing racial/ ethnic group in the United States. The American Asian/Pacific Islander population grew 108% from 3,726,440 in 1980 to 7,273,662 in 1990, thus constituting 2.9% of the entire U.S. population according to the 1990 U.S. Census (U.S. Bureau of the Census, 1991). Projections are that by the year 2020, the Asian American population will be approximately 20.2 million, or about 8% of the total U.S. population. Their diverse immigration history spanning over 200 years, the earliest immigrants came predominantly as indentured laborers, whereas many Asian/Pacific Islanders have of late come to the U.S. as refugees escaping persecution in their home countries. Many more have emigrated in search of better education and economic opportunities. Before World War II, the majority of Asian and Pacific Islander immigrants to the U.S. were from China and Japan. More recently, immigration has included many from diverse Asian groups, such as Nepalese and Tibetans from Central Asia, and from Southeast Asian groups, such as Burmese, Cambodians, Laotians, and Vietnamese, who in turn have many different subgroups, among which the Hmong are perhaps best known. American Samoans, Guamanians, and
Filipinos have also come in more significant numbers. In 1990, 68% of Asian Americans were born outside the U.S. A myriad of issues surround this diverse immigration history, and contribute to a situation of economic polarity among Asian Americans. For example, disparate levels of language proficiency and education clearly contribute to this economic polarity. Unemployment among those of limited education and English language proficiency is double that of Asian Americans who are not disadvantaged in education and language.
The accumulating evidence suggests that Asian Americans are experiencing significant mental health problems. Their diversity (the many ethnic groups, languages, cultures, value and belief systems, and immigration histories, as well as differences in present-day social, economic, and political circumstances) produces an equally diverse range of mental health concerns. The extent to which these issues become problems and how distress is expressed are thought to be affected by multiple factors that may include, but are not limited to: residence area; generational status in the U.S.; degree of acculturation, religious beliefs and value orientations, native language facility, English language proficiency; age, education, economic status, family composition, and degree of family dispersion; immigration as an unaccompanied minor; degree of identification with the country of origin; perception of choice in emigrating to the U.S.; social-political identification; and connection with formal and informal local networks.
Unfortunately, rates of psychopathology have been difficult to assess. It is believed that most existing estimates, which are based on utilization rates among clinical samples, seriously underestimate the actual need in the general Asian American population. Moreover, it is not known to what extent Western diagnostic criteria may overlook culturally-specific symptom expression and culture-bound syndromes. Reports comparing Asian American service use rates to their proportion in the general population evidence disproportionately low rates of admission for health services, regardless of service type. Several studies also report that Asian Americans exhibit more severe disturbances compared to non-Asians, suggesting that they are more likely to endure psychiatric distress for a long time, only coming to the attention of the mental health system at the point of acute breakdown and crisis. Further studies show that Asian Americans are more likely to drop out after initial contact or terminate prematurely from mainstream service settings. Studies have linked such under-use to the shame, stigma, and other cultural factors that influence symptom expression and conceptions of illness, as well as to limited knowledge about the availability of local mental health services, and a tendency to seek more culturally congruent care. The latter may include herbalist, acupuncturist, and other forms of healing. Increased utilization, longer treatment, consumer satisfaction, and positive therapeutic outcomes have been attained by culturally responsive, ethnic-specific services for Asian/Pacific Islanders which emphasize flexible hours, community-based facilities, bi-cultural and bilingual staff, and implementation of culturally congruent treatment plans.
The data point to a great need for delivering more effective mental health services to Asian/Pacific Islander persons, and cultural competence is a fundamental component of such services. A respect for, and understanding of, diverse ethnic and cultural groups, their histories, traditions, beliefs, and value systems, cultural competence in mental health services is integrally important to all levels of care, including the structure and policies of service delivery systems, care planning for the individual consumer/family, and direct treatment intervention. As we move toward managed behavioral health care, the availability of care from culturally competent mental health specialists is a basic concern. In addition, coverage for family- oriented care plans, culturally appropriate interventions, linguistic interpreters, and alternative models of care are threatened.
In the United States, the terms Native American, Indian, and American Indian are commonly used and have been considered interchangeable when referring to aboriginal people of the continental United States, i.e., American Indians, Eskimos, and Aleuts. In this document, Native American also includes the natives of Hawaii. A rich diversity exists among the hundreds of tribes and villages, and within urban Native American communities. Among the better known tribes are the Apache, Cherokee, Navajo, Iroquois, and Sioux (Lakota). Lesser-known groups, of which there are many, include the Cahuilla, Gay Head Wampanoag, Mississippi Choctaw, Red Lake Chippewa, Shivwits, and Tlingit. Census data for 1990 reported approximately 1.9 million American Indian, Eskimo, and Aleut people in the United States (U.S. Bureau of the Census, 1991). About half live on Federal Indian reservations in 33 states, mostly located in the west. The other half live in urban areas, although some reside in small off-reservation communities. The Indian population is young; approximately half are 18 years of age or younger (Nelson, McCoy, Stetter, & Vanderwagen, 1992). Of the 211,014 Native Hawaiians living in the U.S. in 1990, the majority (138,742 or 66%) resided in Hawaii (U.S. Bureau of the Census, 1991). This population faces severely poor health conditions (Mokuau, 1990); Native Hawaiians have the shortest life expectancy of any ethnic group in Hawaii (State of Hawaii, 1987).
Many American Indian and Alaska Native groups have sovereign nation status with the Federal government. For most Indian tribes, sovereignty was specifically retained when they signed treaties with the United States. They are recognized as distinct political entities operating within the American government system, the “nation within a nation” concept. Hawaiian Natives are now seeking to restore their sovereign nation status, which was lost at the time of the overthrow of the Hawaiian monarchy.
The importance of mental health services to Native people can be understood in historical, geographical, educational, and tribal contexts. It is import to understand the impact of colonization on Native people and corresponding issues of mental health (Duran & Duran, 1995). Although some early contacts between Native peoples and Europeans were positive, most were not. From the point of initial contact with Europeans, when there were several million Native Americans, holocaust conditions led to the annihilation of some, and near destruction for other tribes across the Americas and the Hawaiian Islands. Diseases foreign to Native people wiped out over half of the American Indian population, and the impact of these diseases is still being felt. Diseases killed many leaders and elders, thus cutting off tribal leadership, as well as the sources for knowledge and tradition. Furthermore, the power of the medicine people was undermined, because there were no cures for alien diseases about which they had no knowledge. Memories remain among Native Americans about what Whites did through deliberately providing them with infected blankets as “gifts” — an early form of germ warfare (Vogel, 1972).
Forced relocation was another factor which caused many deaths as well as numerous other problems, many of which were mental health related. Dealing with the reality of being conquered, shamed, forced into dependency upon the U.S. government, and the stripping of traditional roles from men, women, and children have impacted tribes for centuries. The pain of the “Trail of Tears,” or long treks to forced relocation areas, remains in the hearts and minds of American Indians today. Other impacts include dealing with broken treaties, being restricted to reservations (historically, an Indian had to have a permit in order to leave the reservation), poverty conditions, and the consequences of not relocating, which often meant destruction and death (O’Sullivan & Handal, 1988; Vogel, 1972). Alcohol was another devastation (Berkhofer, 1978) and is considered to be the current number one problem in Native American areas.
Forced education through boarding schools caused considerable damage to the structure and function of tribal societies as well as to the mental health of Natives. Historically, Native American children were taken from their tribal homes to attend boarding schools sometimes hundreds or thousands of miles away. They were forbidden to speak their tribal language, given new names, and usually a uniform. Their hair was shorn, and they were taught the ways of White society. The early charters for Native American education were the same: to remove the child from the influence of his or her “savage” parents. Today, approximately 25% of Native children attend boarding schools. The effects of boarding schools on tribes extend to the undermining of tribal ways of parenting and traditional child-rearing, to negative messages about Natives, to the forced assimilation of White ways, and to the use of language. There are many stories about a child finally returning home and being unable to speak to his or her parents. Even today, there are counseling groups specifically designed to address the effects of boarding school education experiences.
Through the obligations of many treaties, the U.S. government has had the responsibility for the health care of Native Americans. Typically, these obligations were carried out through the Bureau of Indian Affairs (BIA) of the Department of the Interior, and the Indian Health Service (IHS) of the Public Health Service, which in 1955 assumed primary responsibility for providing health care to Native Americans. Currently, the IHS services approximately 60% of the Indian population (Johnson, 1995). IHS services include clinical care as well as environmental health, facility maintenance, and critical public health functions. The hope was that once this was fully developed and comparable to the nation’s health care systems Congress could relinquish its responsibilities to American Indians. This goal was part of the termination policy formulated by Congress during the Truman and Eisenhower administrations. Under the self-determination policy developed during the Nixon administration, tribes were encouraged to take over governing their health care programs (Flack, 1995). Under Public Law 93-638, 300 tribes across the nation now compact or contract with the Federal government to provide part or all of the health care for their tribal members. In addition, 41 urban Indian health clinics attempt with severely limited funds to serve the most disadvantaged Indians and those from distant tribes who may not be eligible for IHS contract services. Presently, there are numerous agencies/departments involved to varying degrees in providing mental health services to Native Americans. However, there is a lack of clarity regarding the roles of the IHS, the BIA, states, counties, cities, and tribes in mental health care. There are relatively few working agreements among these service delivery systems (WICHE, 1993).
Native Americans appear to be at higher risk for mental disorders than most ethnic groups in the United States (Nelson, McCoy, Stetter & Vanderwagen, 1992). Of great concern is the high prevalence of depression, anxiety, substance abuse, violence, and suicide. Other common mental health problems of Native American individuals are psychosomatic symptoms and emotional problems resulting from disturbed interpersonal and family relationships (Neligh, 1990).
The Native American Panel has many concerns about managed care as a model of health care delivery for Native Americans. Of particular concern is the use of a prepaid or capitated approach to service payment. Issues affecting Native American people are complex and linked to historical events and current experiences which are perpetuated by current events that, on the surface, do not seem related. However, because of the historic trauma experienced by many Native Americans, subtle messages that communicate a lack of belonging to contemporary American society and the continuing assault on Indian sovereignty serve to perpetuate mental health problems. Managed care organizations which do not address these complex issues in a careful and thoughtful manner with Native American consumers, sovereign tribal nations, native organizations, and relevant Federal agencies will only add to the oppression experienced by Native Americans for decades.
The Native American Panel offers the following guidelines toward the goal of developing culturally competent managed care organizations which would serve Native Americans in ever-increasingly effective and respectful ways. In reviewing the system and clinical guidelines, the panel agreed that guidelines for provider competencies would be the same regardless of the setting (urban, suburban, rural, or reservation). All other guidelines were reviewed, with rural-reservation managed care settings kept separately in mind from urban-suburban settings. It is highly likely that the urban-suburban managed care settings would be non-Native American and most likely, non-minority specific. In considering the rural/reservation situation, the panel found it useful to use the Navajo Nation as a reference point. The Navajo Nation has sovereign nation status over its membership residing on or near the reservation, a very large geographic area located in three states (Arizona, New Mexico, and Utah). This illustrates the complexity in developing culturally competent health care for one tribal nation.
The transition into managed care in the delivery of health care services has had an impact on both private and public behavioral health systems. As this transition is taking place, a number of potential risks have surfaced. Professionals and organizations representing individuals from the four groups have concerns about how these major shifts will affect all ethnically diverse populations. Some of these concerns include:
The authors of this document acknowledge that this shift to a new health care delivery system offers a number of potential opportunities for behavioral service delivery as well as for the racial/ethnic communities. Some of these potential opportunities include:
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Source: U.S. Department of Health and Human Services
Substance Abuse and Mental Health Administration
http://mentalhealth.samhsa.gov