Historically, African American teens and young adults have been categorized as a vulnerability population as part of a “high- need” group susceptible to psychological disorders. Multiple national reports here in the United States show that individuals across racial and ethnic minority groups face several challenges accessing mental health care services. The reports point out that there are severe disparities in both the availability and access to mental health care services for those people within certain racial and cultural minority populations. (Foulks, 2004). Research has shown that the rate of psychological distress is significantly higher in these groups than in the general population (U.S. Department of Health and Human Services, 1999). When compared to Whites, African Americans may have more long-lasting symptoms of depression that are more severe and incapacitating than most other minority population groups. (U.S. Department of Health and Human Services, 2001).
Generally, the African American demographic between ages 16-24 years old, is suspicious of health care providers and often refuse to access mental health services until their condition is ‘terminal’. Researchers have highlighted the importance of this clinical mistrust of the patient in the clinical interaction. It is largely due to clinical mistrust and, the stigmas associated with mental health, that African American young adults and teens traditionally avoid seeking treatment until their condition has become too far advanced. Recent studies show that the prevalence of psychiatric disorders in the general U.S. population is high, and the age of onset of these disorders tends to be young (e.g., Kessler, Chiu, Demler, & Walters, 2005). The psychiatric disorders of these young people have been trending upwards within the Black population, particularly when viewed with an eye towards the unique stressors (i.e., neighborhood crime, poverty, high incarceration rates, unemployment) facing this population. The focus of this paper is how the clinical practice of mental health treatment of African American teens and young adults age 16-24, can inform the debate regarding ethnic and cultural competence.
Some key concepts of cultural competence to assist those in clinical practice
Over the past two to three decades there has been a professional outcry for clinicians to recognize the importance of culture and ethnicity in their interactions with, and treatment of patients. Due to excessive migration and globalization, practitioners are now required to understand the complexities of ethnicity and culture. Practitioners must understand the role of culture in the life of each patient, and its potential impact on our understanding of and ability to treat patients effectively. (Hickling, F. W. (2012). Cultural competence has therefore become of primary importance to the clinical practitioner. According to Jeffreys, (2016), cultural competence is generally defined as a multidimensional learning process that integrates transcultural skills in all three dimensions (cognitive, practical, and affective). There has been traditionally, no therapeutic alliance between African American teens and clinicians. There are also unique cultural intricacies of African American’s philosophy of mental illness and treatment practices.
Personal background and identity may have a profound impact on individuals, families, and communities, within and between generations from preconception to after death. Issues of ethnic identity, culture, and alterity in the exchanges between the therapist and patient, can be of ultimate importance as it underscores the interconnectedness of ethnicity and culture in which ethnicity provides a gateway to uncovering culture (Hickling, 2012). Hickling takes the position that, although we can define ethnicity specifically based on an individual’s identification of their country of birth and lineage, defining culture may be more challenging based on its continually evolving state, particularly in light of cultural blending that occurs through the process of migration. (Hickling, 2012). Practitioners must take into account the full scope and complexity of the concepts of ethnicity and culture and in understanding their psychological importance. This entails a careful analysis of key aspects of ethnicity including: a person’s cultural norms and values; the strength, importance and meaning of ethnic identity; the experiences and attitudes such as powerlessness, discrimination and prejudice that are associated with minority status (Phinney, 1996).
It is essential that clinicians are aware of their own “clinician bias.” Multiple studies have shown that failing to adhere to diagnostic criteria resulted in over-diagnosis of African Caribbean patient populations in comparison to European counterparts. (Neighbors, 2003); (Whaley and Geller, 2007). Similarly, clinicians must remain focused on the concept of “cultural relativity” which holds that behaviors and symptoms are culturally determined; yet clinicians are not aware of the cultural differences and as such, are vulnerable to personal biases and likely to make false diagnoses or miss important symptomatology. Clinician bias and cultural relativity play significant roles in patient diagnosis and treatment. If a person is misdiagnosed, then treatment will likely fail and the patient may be at risk for problems becoming worse as a result of delayed or inappropriate treatment. A number of studies have consistently found evidence that certain minority groups are less likely to receive appropriate diagnoses.
Intersectionality and how it applies to clients and their unique needs
Psychologists must consider the diversity that exists among individuals within a particular group as well as the diversity across distinctive groups. Often times ethnicity and diversity intersect with other distinct cultural characteristics which leads to cultural congruency. Such cultural congruency practice delineates empirically supported and theoretically based standards and emphasizes the fine distinction and inter-relatedness between cultural competence and cultural congruence, an important detail frequently overlooked (Marion, et al, 2016; Jeffreys, 2017). According to Jeffreys (2017), simply put, cultural competence is defined as an ongoing process with the expected goal of providing culturally congruent care. It is a tailored “fit” between consumers’ cultural values, beliefs, health practices, and care decisions and actions. The intersection of cultural history, and the psychological constitution of patients has become the basis of a novel analytic model called psychohistoriography. (Hickling, 2012)
Psychohistoriography is an intervention model that was created in Jamaica, with the intention of facilitating therapeutic transformation beyond the boundaries of age, gender, class and culture. In this process individuals translate anecdotal historical information into a visual representation, which is used to identify themes and trends of behavior and life events, and these themes and trends are used to formulate the best therapeutic course. (Hickling, 2012). This intervention was created with the intention of attempting to heal the wounds of history; an aim that is absent from existing psychoanalytic treatment modalities. The social and psychological importance of ethnicity and culture, and its impact on individual functioning particularly in culturally mixed or culturally foreign societies, has demanded that practitioners become culturally competent. (Hickling, 2012)
Best practices for incorporating cultural identity when interacting with clients
- Assessment. One of the most important processes in clinical practice is to conduct the initial psychological assessment in a manner that is sensitive to the client’s ethnic and cultural identity. The use of structured clinical interviews which may assist in reducing clinician bias in the assessment of disorders. This strategy can prove extremely helpful when it comes to developing clinical knowledge on mental health issues impacting youth populations and can ensure that some of the important insights that youth have about their lived experiences are not overlooked.
- The importance of self-labelled ethnic identity and cultural background is also essential and cannot be understated. By allowing the patient to claim his/her ethnic identity, the practitioner is able to explore and attain an accurate identification of the root causes of symptomatology. This highlights the necessity of an in-depth clinical exploration through extensive, empathetic history taking that discount stereotypical assumptions. Hickling, F. W. (2012)
- Psychohistoriographic therapy is important in assessing how personal history experiences affect an individual’s identification within certain cultures and practices.
- Culturally Congruent Practice. This requires an interprofessional collaborative approach visibly inclusive of multiracial and multiheritage individuals, related topics, and cultural congruence in all aspects of daily and professional life, including clinical, community, research, education, and workplace contexts.
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